Explore the vast range of titles available.

We determine how pediatric emergency department (ED) visits changed during the COVID-19 pandemic in a large sample of U.S. EDs. Using retrospective data from January–June 2020, compared to a similar 2019 period, we calculated weekly 2020–2019 ratios of Non-COVID-19 ED visits for adults and children (age 18 years or less) by age range. Outcomes were pediatric ED visit rates before and after the onset of pandemic, by age, disposition, and diagnosis. We included data from 2,213,828 visits to 144 EDs and 4 urgent care centers in 18 U.S. states, including 7 EDs in children's hospitals. During the pandemic period, adult non-COVID-19 visits declined to 60% of 2019 volumes and then partially recovered but remained below 2019 levels through June 2020. Pediatric visits declined even more sharply, with peak declines through the week of April 15 of 74% for children age < 10 years and 67% for 14–17 year. Visits recovered by June to 72% for children age 14–17, but to only 50% of 2019 levels for children < age 10 years. Declines were seen across all ED types and locations, and across all diagnoses, with an especially sharp decline in non-COVID-19 communicable diseases. During the pandemic period, there was 22% decline in common serious pediatric conditions, including appendicitis. Pediatric ED visits fell more sharply than adult ED visits during the COVID-19 pandemic, and remained depressed through June 2020, especially for younger children. Declines were also seen for serious conditions, suggesting that parents may have avoided necessary care for their children.

We examine how emergency department (ED) visits for serious cardiovascular conditions evolved in the coronavirus (COVID-19) pandemic over January–October 2020, compared to 2019, in a large sample of U.S. EDs. We compared 2020 ED visits before and during the COVID-19 pandemic, relative to 2019 visits in 108 EDs in 18 states in 115,716 adult ED visits with diagnoses for five serious cardiovascular conditions: ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), ischemic stroke (IS), hemorrhagic stroke (HS), and heart failure (HF). We calculated weekly ratios of ED visits in 2020 to visits in 2019 in the pre-pandemic (Jan 1-March 10), early-pandemic (March 11–April 21), and later-pandemic (April 22–October 31) periods. ED visit ratios show that NSTEMI, IS, and HF visits dropped to lows of 56%, 64%, and 61% of 2019 levels, respectively, in the early-pandemic and gradually returned to 2019 levels over the next several months. HS visits also dropped early pandemic period to 60% of 2019 levels, but quickly rebounded. We find mixed evidence on whether STEMI visits fell, relative to pre-pandemic rates. Total adult ED visits nadired at 57% of 2019 volume during the early-pandemic period and have only party recovered since, to approximately 84% of 2019 by the end of October 2020. We confirm prior studies that ED visits for serious cardiovascular conditions declined early in the COVID-19 pandemic for NSTEMI, IS, HS, and HF, but not for STEMI. Delays or non-receipt in ED care may have led to worse outcomes.

In 2010 Maryland replaced fee-for-service payment for some rural hospitals with \"global budgets\" for hospital-provided services called Total Patient Revenue (TPR). A principal goal was to incentivize hospitals to manage resources efficiently. Using a difference-in-differences design, we compared eight TPR hospitals to seven similar non-TPR Maryland hospitals to estimate how TPR affected hospital-provided services. We also compared health care use by \"treated\" patients in TPR counties to that of patients in counties containing control hospitals. Inpatient admissions and outpatient services fell sharply at TPR hospitals, increasingly so over the period that TPR was in effect. Emergency department (ED) admission rates declined 12 percent, direct (non-ED) admissions fell 23 percent, ambulatory surgery center visits fell 45 percent, and outpatient clinic visits and services fell 40 percent. However, for residents of TPR counties, visits to all Maryland hospitals fell by lesser amounts and Medicare spending increased, which suggests that some care moved outside of the global budget. Nonetheless, we could not assess the efficiency of these shifts with our data, and some care could have moved to more efficient locations. Our evidence suggests that capitation models require strong oversight to ensure that hospitals do not respond by shifting costs to other providers.

Patient-generated health data (PGHD) encompass health-related information created, recorded, and gathered by patients in their daily lives, and are distinct from data collected in clinical settings. PGHD can offer insight into patients’ everyday health behaviors and conditions, supporting health management and clinical decision-making. The Veterans Health Administration (VHA) has developed a robust infrastructure to collect PGHD, including automatically collected data from digital sensors and patient-entered data. This effort is guided by comprehensive policy and strategy documents to ensure the secure storage and effective use of PGHD. This paper describes the development and implementation of an infrastructure to support PGHD within the VHA and highlights envisioned clinical and research uses of PGHD to advance health care for US veterans. The PGHD database was built to Fast Healthcare Interoperability Resources standards, facilitating secure data storage and exchange of PGHD. Clinical tools, such as the provider-facing dashboards, make PGHD accessible from the electronic health records. Research and evaluation efforts focus on evaluating PGHD’s impact on patient engagement, clinical outcomes, and health care equity. The VHA’s comprehensive PGHD infrastructure represents a significant advancement in personalized health care and patient engagement. The integration of PGHD into clinical practice can enhance shared decision-making and self-management, while research and evaluation efforts can address how to maximize the benefits of PGHD for veterans. The VHA’s approach sets a benchmark for other US health care systems in leveraging PGHD to achieve the broad aims of enhancing stakeholder health care experiences, improving population health and health equity, and reducing costs.

AbstractIntroductionUnited States emergency medicine (EM) post-graduate training programs vary in training length, either 4 or 3 years. However, it is unknown if clinical care by graduates from the two curricula differs in the early post-residency period. MethodsWe performed a retrospective observational study comparing measures of clinical care and practice patterns between new graduates from 4- and 3-year EM programs with experienced new physician hires as a reference group. We included emergency department (ED) encounters from a national EM group (2016–19) between newly hired physicians from 4- and 3- year programs and experienced new hires (>2 years' experience) during their first year of practice with the group. Primary outcomes were at the physician-shift level (patients per hour and relative value units [RVUs] per hour) and encounter-level (72-h return visits with admission/transfer and discharge length of stay [LOS]). Secondary outcomes included discharge opioid prescription rates, test ordering, computer tomography (CT) use, and admission/transfer rate. We compared outcomes using multivariable linear regression models that included patient, shift, and facility-day characteristics, and a facility fixed effect. We hypothesized that experienced new hires would be most efficient, followed by new 4-year graduates and then new 3-year graduates. ResultsWe included 1,084,085 ED encounters by 4-year graduates ( n = 39), 3-year graduates ( n = 70), and experienced new hires ( n = 476). There were no differences in physician-level and encounter-level primary outcomes except discharge LOS was 10.60 min (2.551, 18.554) longer for 4-year graduates compared to experienced new hires. Secondary outcomes were similar among the three groups except 4- and 3-year new graduates were less likely to prescribe opioids to discharged patients, −3.70% (−5.768, −1.624) and − 3.38% (−5.136, −1.617) compared to experienced new hires. ConclusionsIn this sample, measures of clinical care and practice patterns related to efficiency, safety, and flow were largely similar between the physician groups; however, experienced new hires were more likely to prescribe opioids than new graduates. These results do not support recommending a specific length of residency training in EM.

Background. Previous studies have described drug shortages; however, there has been no comprehensive evaluation focusing on US antibacterial shortages. Methods. Drug shortage data from the University of Utah Drug Information Service database were analyzed, with a focus on antibacterial agents from 2001 to 2013. We used descriptive statistics to describe trends in drug shortages, analyze drug classes commonly affected, and investigate whether drugs experienced multiple periods of shortages. Results. One hundred forty-eight antibacterial drugs were on shortage over the 13-year study period, with 26 drugs still active on shortage as of December 2013. The median number of new shortages per year was 10 (interquartile range [IQR], 7). The number of drugs on shortage increased at a rate of 0.35 additional drugs every month (95% confidence interval, .22–.49) from July 2007 to December 2013 (P<.001). The median shortage duration was 188 days (IQR, 366.5). Twenty-two percent of drugs experienced multiple shortage periods. Conclusions. There were a substantial number of drug shortages from 2001 to 2013, with a dramatic rise in shortages since 2007. Shortages of agents used to treat multidrug-resistant infections are of concern due to continued transmission and limited treatment options.

Background Digital health devices (DHDs), technologies designed to gather, monitor, and sometimes share data about health-related behaviors or symptoms, can support the prevention or management of chronic conditions. DHDs range in complexity and utility, from tracking lifestyle behaviors (e.g., pedometer) to more sophisticated biometric data collection for disease self-management (e.g., glucometers). Despite these positive health benefits, supporting adoption and sustained use of DHDs remains a challenge. Objective This analysis examined the prevalence of, and factors associated with, DHD use within the Veterans Health Administration (VHA). Design National survey. Participants Veterans who receive VHA care and are active secure messaging users. Main Measures Demographics, access to technology, perceptions of using health technologies, and use of lifestyle monitoring and self-management DHDs. Results Among respondents, 87% were current or past users of at least one DHD, and 58% were provided a DHD by VHA. Respondents 65 + years were less likely to use a lifestyle monitoring device (AOR 0.57, 95% CI [0.39, 0.81], P  = .002), but more likely to use a self-management device (AOR 1.69, 95% [1.10, 2.59], P  =  . 016). Smartphone owners were more likely to use a lifestyle monitoring device (AOR 2.60, 95% CI [1.42, 4.75], P  = .002) and a self-management device (AOR 1.83, 95% CI [1.04, 3.23], P  = .037). Conclusions The current analysis describes the types of DHDs that are being adopted by Veterans and factors associated with their adoption. Results suggest that various factors influence adoption, including age, access to technology, and health status, and that these relationships may differ based on the functionalities of the device. VHA provision of devices was frequent among device users. Providing Veterans with DHDs and the training needed to use them may be important factors in facilitating device adoption. Taken together, this knowledge can inform future implementation efforts, and next steps to support patient-team decision making about DHD use.

There is limited data comparing pediatric return visits between pediatric emergency departments (PED) and general EDs. We hypothesized that the 72-hour return rate is higher for patients discharged from general EDs than from PEDs. We analyzed all PED visits in a large, national emergency medical group that had a repeat ED visit to the same site within 72 hours between 2016-2019. Associated visit- and facility-level characteristics analyzed in the model included patient age, Emergency Severity Index and triage level, sex, insurance type, categorized reason for visit, facility type, facility size, trauma status, teaching status, year, and month. Diagnostic categories were defined using the Agency for Healthcare Research and Quality clinical classification software for diagnosis codes. The outcome variable was 72-hour returns. We analyzed returns at the visit-level using descriptive statistics and at the facility-month level using logistic regression to adjust for potential confounders. A total of 2,588,680 pediatric visits were included: 1,821,800 from 137 general EDs and 766,880 from 7 PEDs. The proportion of children returning to a PED within 72 hours was 1.1 percentage points higher than at a general ED (3.5% vs. 2.4%). The adjusted odds ratio for a 72-hour return visit was 1.3 (confidence interval 1.15-1.38) in PEDs compared to general EDs. Pediatric patients discharged from PEDs had a higher rate of 72-hour return visits than those discharged from general EDs. These findings merit further investigation into factors driving these differences to identify best practices and optimize care across ED settings.

We determine how aggregate costs have changed for commonly used emergency department (ED) medications, and assess drivers of cost increases. Using the National Hospital Ambulatory Medical Care Survey (NHAMCS), we identified the top 150 ED medications administered and prescribed at discharge in 2015. We used average wholesale prices (AWP) for each year from 2006 to 15 from the Red Book (Truven Health Analytics Inc.). Average wholesale price per patient (AWPP) was calculated by dividing AWP by drug uses. This was then multiplied by the total drug administrations or prescriptions to estimate the total cost in a given the year. All prices were converted to 2015 dollars. Aggregate costs of drugs administered in the ED increased from $688.7 million in 2006 to $882.4 million in 2015. For discharge prescriptions, aggregate costs increased from $2.031 billion in 2006 to $4.572 billion in 2015. AWPP for drugs administered in the ED in 2015 was 14.5% higher than in 2006 and 24.3% higher at discharge. The largest absolute increase in AWPP for drugs administered was for glucagon, which increased from $111 in 2006 to $235 in 2015. The largest AWPP increase at discharge was for epinephrine auto-injector, which increased from $124 in 2006 and to $481 in 2015. Over the course of the study period, the aggregate costs of the most common medications administered in the ED increased by 28% while the costs of medications prescribed at discharge increased 125%.