Emergency department reorganisation introducing increased autonomy: A mixed effects approach to evaluate the effects of a national policy.

BACKGROUND: In 2007, a Danish national policy to future-proof emergency department (ED) performance was launched. The policy included several recommendations for the management and organisation of care that essentially introduced greater ED autonomy. In this study, we evaluate the effects of increased ED autonomy on readmission, mortality and episode costs for two large patient groups. METHOD: A non-randomised stepped wedge study-design where all EDs gradually implemented the policy at different steps during the study period (2008-2016). The timing and extent of policy implementation was determined from a retrospective cross-sectional survey of all 21 Danish EDs. This was linked to all episodes of hip fracture (n = 79,697) and erysipelas (n = 39,900) identified in the Nation Patient Registry and with episode-level outcomes. Mixed effect models were specified for the outcomes of 30-day readmission, 30-day mortality and episode costs, and adjusted for relevant ED- and episode-level heterogeneity. RESULTS: Increased ED autonomy was associated with more readmissions (p<0.05) and higher episode costs (p<0.001) in hip fracture episodes. In erysipelas episodes, no general associations were found. When restricted to night-time admissions, increased ED autonomy was associated with poorer outcomes for erysipelas episodes and increased episode costs for both patient groups. CONCLUSION: The intended policy effects were not found for these two patient groups; in fact, reorganisation appeared to have harmed hip fracture patients and increased episode costs. Uncertainty remains regarding the longer-term consequences.

Organisational determinants and consequences of diagnostic discrepancy in two large patient groups in the emergency departments: a national study of consecutive episodes between 2008 and 2016.

BACKGROUND: Diagnostic discrepancy (DD) is a common phenomenon in healthcare, but little is known about its organisational determinants and consequences. Thus, the aim of the study was to evaluate this among selected emergency department (ED) patients. METHOD: We conducted an observational study including all consecutive ED patients (hip fracture or erysipelas) in the Danish healthcare sector admitted between 2008 and 2016. DD was defined as a discrepancy between discharge and admission diagnoses. Episode and department statistics were retrieved from Danish registers. We conducted a survey among all 21 Danish EDs to gather information about organisational determinants. To estimate the results while adjusting for episode- and department-level heterogeneity, we used mixed effect models of ED organisational determinants and 30-day readmission, 30-day mortality and episode costs (2018-DKK) of DDs. RESULTS: DD was observed in 2308 (3.3%) of 69,928 hip fracture episodes and 3206 (8.5%) of 37,558 erysipelas episodes. The main organisational determinant of DD was senior physicians (nonspecific medical specialty) being employed at the ED (hip fracture: odds ratio (OR) 2.74, 95% confidence interval (CI) 2.15-3.51; erysipelas: OR 3.29, 95% CI 2.65-4.07). However, 24-h presence of senior physicians (nonspecific medical specialty) (hip fracture) and availability of external senior physicians (specific medical specialty) (both groups) were negatively associated with DD. DD was associated with increased 30-day readmission (hip fracture, mean 9.45% vs 13.76%, OR 1.46, 95% CI 1.28-1.66, p < 0.001) and episode costs (hip fracture, 61,681 DKK vs 109,860 DKK, log cost 0.58, 95% CI 0.53-0.63, p < 0.001; erysipelas, mean 20,818 DKK vs 56,329 DKK, log cost 0.97, 95% CI 0.92-1.02, p < 0.001) compared with episodes without DD. CONCLUSION: DD was found to have a negative impact on two out of three study outcomes, and particular organisational characteristics seem to be associated with DD. Yet, the complexity of organisations and settings warrant further studies into these associations.

Healthcare costs attributable to the treatment of patients with spinal metastases: a cohort study with up to 8 years follow-up.

BACKGROUND: Cancer treatment, and in particular end-of-life treatment, is associated with substantial healthcare costs. The purpose of this study was to analyse healthcare costs attributable to the treatment of patients with spinal metastases. METHODS: The study population (n = 629) was identified from clinical databases in Denmark. Patients undergoing spinal metastasis treatment from January 2005 through June 2012 were included. Clinical data were merged with national register data on healthcare resource use, costs and death date. The analytic period ranged from treatment initiation until death or administrative censoring in October 2013. Analysis of both survival and costs were stratified into four treatment regimens of increasing invasiveness: radiotherapy (T1), decompression (T2), decompression + instrumentation (T3) and decompression + instrumentation + reconstruction (T4). Survival was analysed using Kaplan-Meier curves. Costs were estimated from a healthcare perspective. Lifetime costs were defined as accumulated costs from treatment initiation until death. The Kaplan-Meier Sampling Average method was used to estimate these costs; 95% CIs were estimated using nonparametric bootstrapping. RESULTS: Mean age of the study population was 65.2 years (range: 19-95). During a mean follow-up period of 9.2 months (range: 0.1-94.5 months), post treatment survival ranged from 4.4 months (95% CI 2.5-7.5) in the T1 group to 8.7 months (95% CI 6.7-14.1) in the T4 group. Inpatient hospitalisation accounted for 65% and outpatient services for 31% of the healthcare costs followed by hospice placements 3% and primary care 1%. Lifetime healthcare costs accounted for €36,616 (95% CI 33,835-39,583) per T1 patients, €49,632 (95% CI 42,287-57,767) per T2 patient, €70997 (95% CI 62,244-82,354) per T3 patient and €87,814 (95% CI 76,638-101,528) per T4 patient. Overall, 45% of costs were utilised within the first month. T1 and T4 patients had almost identical distributions of costs: inpatient hospitalisation averaged 59% and 36% for outpatient services. Costs of T2 and T3 were very similarly distributed with an average of 71% for inpatient hospitalisation and 25% for outpatient services. CONCLUSION: The index treatment accounts for almost half of lifetime health care costs from treatment initiation until death. As expected, lifetime healthcare costs are positively association with invasiveness of treatment.