Emergency care and emergency care research

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

2. Overview • Demographics • Quality of emergency care • Future directions

3. Demographics of emergency care • 124 million ED visits in 2008 (CDC)

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

5. Demographics of emergency care • Realities • Most ED patients have insurance (CDC) • Recent increases in visits by Medicaid & uninsured patients (JAMA 2010)

6. Demographics of emergency care • Realities • According to most recent estimates, on 8% of ED visits were non-urgent

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

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

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

10. Demographics of emergency care • But EDs are a victim of their own success • Higher demand + Less Space = ED crowding

11. Demographics of emergency care • Crowding matters • Longer waits • Poorer quality • Higher complications • Boarding • Higher medical errors • Higher mortality rates

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

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

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

15. AHRQ’s emergency care portfolio • The importance of quality (Romano) • The importance of timing (Carr) • Clinical focus: CO poisoning (Iqbal)

16. Focus on quality • Large variety of case-mix • Quality of care means something different to different people • Depends on why you’re there

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

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

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 • SAH, AMI, Stroke, Trauma • The future • Understanding the relationship between timeliness and outcomes for more “urgent” conditions

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 Resource Consumption Minimizing misses

21. Moving beyond associations… • Fixing the emergency care system • Within the ED • Ensuring evidence based best-practices • Streamlining operations • Optimizing clinical service delivery

22. Moving beyond associations… • Fixing the emergency care system • Between the ED and hospital • Reducing boarding • Improving care transitions

23. Moving beyond associations… • Fixing the emergency care system • Among EDs and hospitals • Regionalization of emergency services • Coordination of care at the community-level

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

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

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

27. Questions?