Cost and Visit Duration of Same-Day Access at an Academic Ophthalmology Department vs Emergency Department.

Importance: Convenient outpatient access for ophthalmology patients seeking urgent care could offer savings compared with an emergency department (ED) visit. Objective: To evaluate the costs and visit durations of same-day access (SDA) in an ophthalmology department at an academic medical center vs ED care. Design, Setting, and Participants: This single-center study was a retrospective quality improvement analysis of an institutional electronic medical record system at the Wilmer Eye Institute clinics and the Johns Hopkins Hospital ED. On June 1, 2015, the Wilmer Eye Institute and Johns Hopkins Hospital initiated an official policy of providing SDA to patients calling for appointments (ie, the same-day project). All ophthalmology clinic locations created same-day appointment slots for at least 1 practitioner. In recognition of seasonal variations in patient visit volumes, the 10 months before implementation (August 1, 2014, to May 31, 2015) were compared with complementary periods in 2015 to 2016 and 2016 to 2017. Main Outcomes and Measures: The study tabulated encounters, charges, and visit length for outpatients seen on the same day or by previously scheduled appointments. For the ED patients, volume, diagnoses, charges, and length of stay data were collected. The numbers of SDA patients who indicated urgency were tabulated. Results: The number of SDA patients increased from 22 781 to 26 579 for the first year after SDA implementation. The mean charge was $258 (95% CI, $250-$266; median, $184; interquartile range [IQR], $175-$320), and the mean clinic transit time was 1.55 hours (95% CI, 1.54-1.57 hours; median, 1.28 hours). For patients seeking eye care in the ED, the mean professional fee was $401 (95% CI, $390-$411; median, $360; IQR, $255-$500), the mean (SD) total hospital charge was $1040 ($999) (95% CI, $729-$1079; median, $1002; IQR, $334-$1429), and the mean length of stay was 7.30 hours (95% CI, 7.01-7.57 hours; median, 7.20 hours). The top 4 ophthalmic diagnoses for ED patients were conjunctivitis, cornea abrasion, iritis, and visual loss, which were unchanged after SDA implementation. In calendar year 2017, a total of 4062 SDA patients reported urgency; their estimated savings in charges compared with an ED visit were $580 866 in professional fees and $3 176 484 in hospital charges. Conclusions and Relevance: Same-day access appears to be less expensive and to require less time in the health care system than a visit to the ED for an ophthalmic diagnosis. Substantial savings in time and money might be achieved if urgent eye care is delivered in the clinic rather than the ED.

Nonpruritic erythematous plaques.

A 43-year-old man visiting Texas from Hawaii sought care at our dermatology clinic for nonpruritic erythematous plaques on his chest, back, and extremities. The patient reported occasional numbness in his fingers and feet, but denied constitutional symptoms. The patient, who'd had these symptoms for a year, had been previously diagnosed with chronic urticaria and treated with oral antihistamines. He reported that the lesions were never particularly pruritic and he had not responded to previous treatments. An avid outdoorsman, our patient was born and raised in Texas and had been living in Hawaii. His past medical history was significant for severe hand eczema and when asked about medications he was taking, he listed cetirizine, doxepin, and hydroxyzine. On physical examination the patient had multiple pink to red, nonscaly to minimally scaly flat plaques on his forehead, chest, proximal upper extremities, lower back, and distal lower extremities. A 4-mm punch biopsy was taken from a lesion on his lower back and sent for histologic evaluation. The patient's erythrocyte sedimentation rate, rapid plasma reagin, and complete blood count were all within normal limits. What is your diagnosis? How would you treat this patient?