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ACEP perspective

ACEP perspective. Sandra Schneider MD FACEP Immediate PAST President ACEP. ACEP. 30,000 members – 60% attendings (consultants). r. Chronic renal disease. 6.6% Medicare population has CKD, 1.2% ESRD 8.1% of MCMA population has CKD, 2.7% ESRD 19.4% of MC dollars on CKD, 8.2% on ESRD

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ACEP perspective

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  1. ACEP perspective Sandra Schneider MD FACEP Immediate PAST President ACEP

  2. ACEP • 30,000 members – 60% attendings (consultants)

  3. r

  4. Chronic renal disease 6.6% Medicare population has CKD, 1.2% ESRD 8.1% of MCMA population has CKD, 2.7% ESRD 19.4% of MC dollars on CKD, 8.2% on ESRD Growing 2% per year o

  5. 100% 80% 20 percent = zero cost. 60% 40% 20% 0% total cost 0% 0% 20% 40% 60% 80% 100% 20% of people Cost distribution of care (Working Americans) Halvorson & Isham, Epidemic of Care, Jossey-Bass: 2003

  6. 100% 70 percent = 10 percent of the cost 80% 60% 40% 20% 0% 0% 20% 40% 60% 80% 100% 10% total cost 70% of people Cost distribution of care (Working Americans) Halvorson & Isham, Epidemic of Care, Jossey-Bass: 2003

  7. 1% of people 100% 80% 30% total cost 60% 1 percent = 30 percent of cost. 40% 20% 0% 0% 20% 40% 60% 80% 100% Cost distribution of care (Working Americans) Halvorson & Isham, Epidemic of Care, Jossey-Bass: 2003

  8. Price Waterhouse Appropriate spending/potential saving

  9. Potential savings

  10. Unnecessary ER visits

  11. Malpractice

  12. Safety • Human factors engineering • Near misses • Environmental features

  13. Quality measures in the US

  14. Quality measures in the US

  15. Quality measures in the US

  16. How Quality becomes a measure Promoted by an interested group Vetted before National Quality Forum Used by Center for Medicaid and Medicare Services Used for bonus for physicians (1%) Used for bonus for hospitals Publically reported

  17. Quality measures • Currently 1% increase in payments (MA/MC) for reporting • Increases to 1.5% • Penalty 2015 1.5% - 2% in 2016 for not reporting • Physician compare website up this year • Tied to maintenance of certification (board certification)

  18. Healthgrades.com

  19. Hospitalcompare.com

  20. Healthgrades.com

  21. Measure crazy? • 2030 measures registered with AHRQ • NQF has endorsed 467 • 104 EM related

  22. Early measures chest pain • ECG within 5 min • Door to needle 30 m/ door to balloon 90 m • Aspirin within 24 hours • Beta blocker within 24 hours

  23. Early measures CAP adults • Vital signs documented • Pulse ox • Mental status noted • Blood cultures before antibiotics • Antibiotics within 4 hours (now 6) • Correct initial antibiotic

  24. Quality vs creativity • All patients with fever or cough get azithromycin • Placing topical antibiotic on all elder patients • Standing ECG’s in waiting room • Blood cultures drawn on all elder patients • Doctor in triage (door to doc time) • Tylenol for all patients with pain

  25. Newer measures - EM • Aspirin on arrival (ends in 2014) • Door to needle/ door to balloon • Thrombolytics for stroke (2015) • DVT anticoagulation • Blood culture before antibiotics • Antibiotic within 6 hours (ends in 2014) • Appropriate antibiotic • Patient’s experience of care

  26. 2012 measures EM • Time to transfer for MI • Troponin within 60 min arrival • Treat and release time discharged patients • Door to doc time

  27. New measures 2014 • ED time arrival to departure admitted patients • ED time decision to admit to departure admitted patients • Pts left without being seen • Time to pain med for long bone fractures

  28. New measures • Central line related sepsis • Catheter associated UTI (2014) • Healthcare worker influenza vaccination (2015)

  29. The bad • Bad or no science

  30. Radiology + AMA • #4 No of CT abd/pelvis/combined without contrast followed by with contrast • #5 overuse CT perfusion for atruamatic HA IN THE ED • #9 MD must report all previous CTs in last 12 month • #12 report exposure to flouro >10 min

  31. AMA and Radiology • #6 overuse of CT head for atraumatic HA • Over 18, ‘immediate CT’ • Exceptions: LP or neuro findings, SAH, complicated or thunderclap HA, HIV, tumor or mass, anticoagulation – quote Canadian GL 2008 • “The ED physician’s primary goal is to R/O a secondary cause for HA and then get the patient out quickly – HEADACHE 2009

  32. The bad • Bad or no science • Clinical policy misinterpretion • Competing interests/conflicting goals • An acceptable miss rate is 0.0000000000000%

  33. To date silent on crowding

  34. Is it quality or money? • Medicare measures: We are concerned about the excessive irradiation to our patients… • Nearly all patients >age 65

  35. Is it quality or money? • Medicare: We want to reduce the amount of radiation by decreasing the number of CT scans and MRI’s

  36. Bright spots • Full capacity protocol • Georgetown solution • Registries • ACEP’s Quality and Performance Committee

  37. ACEP led initiatives • Medical liability reform • Basic tenets • Transparent process involving all affected • Evidence based • NQF endorsed

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