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Background Older adults in rural geographies may be uniquely vulnerable to difficulty accessing outpatient care, and therefore more reliant on emergency department (ED) care. We compared ED utilization for ambulatory care sensitive conditions (ACSCs) and emergency care sensitive conditions (ECSCs) among rural and urban Medicare beneficiaries. Methods We conducted a pooled cross-sectional analysis of 2016–2020 Medicare Current Beneficiary Survey data, assessing ED visitation rates for ACSCs and ECSCs. We present ED visit rates per 100 beneficiary-years and estimated logistic regression models to quantify the odds of having any ED visit, any ACSC-related ED visit, or any ECSC-related ED visit in a given year among older adults in rural and urban areas, adjusting for sociodemographic and health characteristics. Results Our sample included 70,830 beneficiary-years, with 17,052 (24.1%) being from beneficiaries residing in rural areas. Rural beneficiaries had higher ED visit rates, with a weighted mean (SD) of 59.2 ED visits (14.1) per 100 beneficiary-years across study years, 11.5 (1.3) for ACSC-related, and 20.6 (3.5) for ECSC-related visits, compared to 43.2 (9.2), 7.2 (0.9), and 15.2 (1.9) ED visits, respectively, for urban beneficiary-years. In adjusted models, rural beneficiaries had a 49% higher odds of having an ED visit (OR: 1.49, 95% CI: 1.40–1.59), a 30% higher odds of an ACSC-related ED visit (OR: 1.30, 95% CI: 1.04–1.64), and a 26% higher odds of an ECSC-related ED visit (OR: 1.26, 95% CI: 1.05–1.50) within a given year when compared to urban counterparts. Conclusions Rural Medicare beneficiaries consistently showed higher ED utilization for ACSCs and ECSCs compared to urban beneficiaries, highlighting potential disparities in healthcare access and a need for targeted or policy-based interventions.

Introduction: The “4Ms” model – What Matters, Medication, Mentation, and Mobility – is increasingly gaining attention in age-friendly health systems, yet a feasible approach to identifying what matters to older adults in the emergency department (ED) is lacking. Adapting the “What Matters” questions to the ED setting, we sought to describe the concerns and desired outcomes of both older adult patients seeking ED care and their treating clinicians. Methods: We conducted 46 dyadic semi-structured interviews of cognitively intact older adults and their treating clinicians. We used the “What Matters” conversation guide to explore patients’ 1) concerns and 2) desired outcomes. We then asked analogous questions to each patient’s treating clinician regarding the patient’s priorities. Interviews were professionally transcribed and coded using an inductive approach of thematic analysis to identify emergent themes. Results: Interviews with older adults lasted a mean of three minutes, with a range of 1–8 minutes. Regarding patients’ concerns, five themes emerged from older adults: 1) concern through a family member or outpatient clinician recommendation; 2) no concern, with a high degree of trust in the healthcare system; 3) concerns regarding symptom cause identification; 4) concerns regarding symptom resolution; and 5) concerns regarding preservation of their current status. Regarding desired outcomes, five priority themes emerged among older adults: 1) obtaining a diagnosis; 2) returning to their home environment; 3) reducing or resolving symptoms; 4) maintaining self-care and independence; and 5) gaining reassurance. Responding to what they believed mattered most to older adult patients, ED clinicians believed that older adults were concerned primarily about symptom cause identification and resolution and primarily desired a return to the home environment and symptom reduction. Conclusion: This work identifies concerns and desired outcomes of both older adult patients seeking ED care and their treating clinicians as well as the feasibility of incorporating the “What Matters” questions within ED clinical practice.

ObjectiveDesignTraditional encounter-based analyses overlook downstream costs and complications that follow emergency department (ED) care. To enable more comprehensive evaluations, we developed standardised episode of care definitions for five common, high-cost conditions: chest pain, congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease (COPD) and suicidality.A two-round modified Delphi panel study was conducted following a literature review and evidence synthesis. Using structured surveys with anonymous feedback, panellists rated candidate criteria. To be retained in the final episode definitions, criteria were required to meet a predefined validity threshold without panellist disagreement. Data were analysed descriptively, and meeting deliberations were recorded and reviewed thematically.SettingVirtual, supported by an online survey platform.ParticipantsA multidisciplinary panel of 11 experts in emergency medicine and relevant clinical specialties with 9 members participating in each round.OutcomesCriteria to determine inclusion, exclusion (including pre-trigger, post-trigger and event exclusion) and risk-adjustment standards for constructing ED-based episodes of care.ResultsCandidate criteria were presented to the panel by condition: 30 for chest pain, 54 for CHF, 30 for COPD, 79 for pneumonia and 375 for suicidality. Following deliberations and re-rating, the number of valid criteria was reduced, primarily in the episode exclusion category. Thematic analysis highlighted trade-offs between episode exclusion criteria and the use of risk adjustment to account for heterogeneity.ConclusionsOperational definitions for ED-based episodes of care for five conditions were established. These may support healthcare administrators, policymakers and researchers in evaluating variation in ED care delivery and its downstream cost and outcomes.

AbstractQuality measures increasingly influence the delivery and reimbursement of care provided in emergency departments. While emergency physicians are accustomed to using quality measures to improve care delivery, payors, including the Centers for Medicare and Medicaid Services (CMS), are increasingly adjusting reimbursement to measure performance as a means to bend the cost curve and improve the value of healthcare services. The American College of Emergency Physicians Quality and Patient Safety Committee presents this whitepaper to guide practicing emergency physicians through the policy context of implementing measures in emergency care and understanding its impact reimbursement. This paper summarizes current CMS programs such as the merit‐based incentive payment system (MIPS), MIPS value pathways, and alternative payment models and various reporting mechanisms. It is crucial for emergency physicians to understand the quality measure development process, the need for more emergency medicine‐specific quality measures, and the growing significance of measure performance in the payment of emergency care.

Introduction: Clear communication is essential for emergency medical services (EMS) clinicians to assess a situation and make appropriate transport decisions. When barriers are present that impede communication between emergency responders and patients, EMS clinicians report difficulty navigating these encounters. As communication barriers potentially delay definitive care, it remains unclear the amount of time that EMS clinicians spend on scene during these encounters and how often they result in non-transport. In this study we sought to characterize the association between the presence of communication barriers, time spent on scene, and non-transport. Methods: We conducted an observational analysis using 2022 data from the ESO Data Collaborative, a deidentified national prehospital electronic health record dataset. Encounters were restricted to 9-1-1 responses in which the responding ambulance was first on scene, the patient was alive, ≥ 18 year of age, and able to refuse transport. The primary outcomes were time on scene and non-transport. We used logistic regression models to estimate non-transport by communication barrier (including non-English language preference, speech disability, deaf or hard of hearing, and blind or low vision) and control for key patient and encounter characteristics. Results: Of 3,477,008 EMS responses, 233,084 (6.7%) resulted in non-transport and 99,263 (2.9%) had a communication barrier identified. Among encounters with a communication barrier identified, EMS clinicians spent more time on scene with patients who were not transported (21.0 minutes) compared to patients who were transported for definitive care (15.9 minutes). Compared to those without an identified barrier, encounters with a patient who had a non-English language preference (odds ratio [OR] 0.51, confidence interval [CI] 0.49-0.53, P < .001), patients who had a speech disability (OR 0.36, CI 0.33-0.40, P < .001), were deaf or hard of hearing (OR 0.71, CI 0.66-0.76, P < .001), or were blind or had low vision (OR 0.80, CI 0.69-0.92, P < .001) were less likely to result in non-transport, with non-transport rates of 3.6%, 1.9%, 4.0%, and 4.4% respectively. Conclusion: Encounters with communication barriers were less likely to end in non-transport. When communication barriers were identified, EMS clinicians spent 32% (5.1 minutes) longer on scene on encounters that resulted in non-transport, showing that EMS clinicians may be dedicating additional time and resources caring for this population.

Clinician expertise has been associated with improved patient outcomes, yet ED clinicians often work in various clinical settings beyond the ED and, therefore, may risk expertise by having less clinical focus. We sought to describe clinical focus among the emergency care workforce nationally. Using the 2017 Medicare Public Use Files (PUF), we performed a cross-sectional analysis of clinicians receiving reimbursement for emergency care Evaluation & Management (E/M) services from Medicare fee-for-service Part B. Clinicians were categorized by type as EM physicians, non-EM physicians, and advanced practice providers (APPs). The primary outcome was the clinical focus of the individual clinician, defined as the proportion of E/M services within the ED setting relative to a clinician's total E/M services across all practice settings. Of 65,710 unique clinicians providing care to Medicare fee-for-service beneficiaries in the ED setting, 39,016 (59.4%) were classified as EM physicians, 8123 (12.4%) as non-EM physicians, and 18,571 (28.5%) as APPs. The individual clinician median focus was 92.8% (interquartile range [IQR]: 87.0, 100.0) for EM physicians, 45.2% (IQR: 5.1, 97.0) for non-EM physicians, and 100.0% (IQR: 96.3, 100.0) for APPs. EM physicians have twice as much clinical focus in comparison to non-EM physicians providing emergency care to Medicare fee-for-service beneficiaries. These findings underscore the importance of diverse training and certification programs to ensure access to clinically focused ED clinicians.

INTRODUCTION After emergency department (ED) discharge, persons living with cognitive impairment (PLWCI) and their care partners are particularly at risk for adverse outcomes. We sought to identify the barriers experienced by care partners of PLWCI during ED discharge care transitions. METHODS We conducted a qualitative study of 25 care partners of PLWCI discharged from four EDs. We used the validated 4AT and care partner‐completed AD8 screening tools, respectively, to exclude care partners of older adults with concern for delirium and include care partners of older adults with cognitive impairment. We conducted recorded, semi‐structured interviews using a standardized guide, and two team members coded and analyzed all professional transcriptions to identify emerging themes and representative quotations. RESULTS Care partners’ mean age was 56.7 years, 80% were female, and 24% identified as African American. We identified four major barriers regarding ED discharge care transitions among care partners of PLWCI: (1) unique care considerations while in the ED setting impact the perceived success of the care transition, (2) poor communication and lack of care partner engagement was a commonplace during the ED discharge process, (3) care partners experienced challenges and additional responsibilities when aiding during acute illness and recovery phases, and (4) navigating the health care system after an ED encounter was perceived as difficult by care partners. DISCUSSION Our findings demonstrate critical barriers faced during ED discharge care transitions among care partners of PLWCI. Findings from this work may inform the development of novel care partner‐reported outcome measures as well as ED discharge care transition interventions targeting care partners.

AbstractThe Centers for Medicare & Medicaid Services (CMS) implemented the Merit‐based Incentive Payment System (MIPS) to accelerate the transition of physician payment toward value‐based care models and away from traditional fee‐for‐service payment programs. In recent years, CMS has sought to modify the program by developing a MIPS Value Pathway (MVP) framework intended to use existing and future physician quality and cost measures to reward value‐based care delivery. This article describes the multi‐step process of the MVP Task Force, convened by the American College of Emergency Physicians (ACEP) to develop an emergency medicine‐specific MVP proposal informed by diverse stakeholder perceptions regarding: (1) which existing quality measures reflect high quality emergency care, and (2) the degree to which emergency clinicians can impact clinical outcomes and cost for the care domains captured by existing quality measures. The MVP Task Force synthesized stakeholder feedback and underwent a consensus‐building approach to develop the “Adopting Best Practices and Promoting Patient Safety within Emergency Medicine” MVP, recently reviewed and approved by CMS for national implementation starting in 2023. Our process and findings have broad implications for clinicians, administrators, and policymakers navigating the continued transition to value‐based care in conjunction with CMS's implementation of the MVP framework.