Emergency department monitor alarms rarely change clinical management: An observational study.

STUDY OBJECTIVE: Monitor alarms are prevalent in the ED. Continuous electronic monitoring of patients' vital signs may alert staff to physiologic decompensation. However, repeated false alarms may lead to desensitization of staff to alarms. Mitigating this could involve prioritizing the most clinically-important alarms. There are, however, little data on which ED monitor alarms are clinical meaningful. We evaluated whether and which ED monitor alarms led to observable changes in patients' ED care. METHODS: This prospective, observational study was conducted in an urban, academic ED. An ED physician completed 53 h of observation, recording patient characteristics, alarm type, staff response, whether the alarm was likely real or false, and whether it changed clinical management. The primary outcome was whether the alarm led to an observable change in patient management. Secondary outcomes included the type of alarms and staff responses to alarms. RESULTS: There were 1049 alarms associated with 146 patients, for a median of 18 alarms per hour of observation. The median number of alarms per patient was 4 (interquartile range 2-8). Alarms changed clinical management in 8 out of 1049 observed alarms (0.8%, 95% CI, 0.3%, 1.3%) in 5 out of the 146 patients (3%, 95% CI, 0.2%, 5.8%). Staff did not observably respond to most alarms (63%). CONCLUSION: Most ED monitor alarms did not observably affect patient care. Efforts at improving the clinical significance of alarms could focus on widening alarm thresholds, customizing alarms parameters for patients' clinical status, and on utilizing monitoring more selectively.

Association of a Risk Evaluation and Mitigation Strategy Program With Transmucosal Fentanyl Prescribing.

Importance: Transmucosal immediate-release fentanyl (TIRF) drugs are potent, rapid-acting opioids approved to treat breakthrough pain in patients with cancer who are tolerant to other around-the-clock opioid analgesics. In March 2012, a US Food and Drug Administration-approved Risk Evaluation and Mitigation Strategy (REMS) was implemented, mandating prescribers, distributors, pharmacies, and patients to enroll in the REMS to prescribe, dispense, or receive TIRF drugs. Objective: To evaluate the association of the TIRF-REMS Access Program with TIRF prescribing. Design, Setting, and Participants: Cohort study using an interrupted time series analysis of TIRF prescriptions to Medicare Part D beneficiaries nationwide from 2010 to 2014. Data were analyzed from August 2017 through July 2018. Main Outcomes and Measures: Prescribing of TIRF per 100 000 Medicare Part D beneficiaries, overall and stratified by cancer status; percentage of TIRF prescriptions for patients without cancer, overall and by brand; and percentage of TIRF prescriptions for patients without known opioid tolerance, defined as patients prescribed at least 60 morphine milligram equivalents per day, overall and by brand. Results: There were 99 601 TIRF prescriptions written by 8619 clinicians to 10 472 patients. Most of the patients (79%) were younger than 65 years (mean [SD] age, 56 [13] years), and most (67%) did not have cancer. Implementation of TIRF-REMS was associated with a 26.7% relative level decrease in TIRF prescribing (95% CI, -33.3% to -19.4%; P < .001) but was followed by 2.0% monthly increases in prescribing (95% CI, 1.3% to 2.7%; P < .001). Sensitivity analyses that accounted for overall opioid prescribing trends were consistent with these findings. Furthermore, there were no significant changes associated with REMS implementation in the level (0.47%; 95% CI, -5.36% to 4.69%; P = .85) or trend (0.16%; 95% CI, -0.06% to 0.37%; P = .15) of the percentage of prescriptions for patients without cancer. However, a sensitivity analysis that used a broader cancer definition found implementation was associated with a 7.2% (95% CI, -13.5% to -0.48%; P = .04) level decrease in the percentage of TIRF prescriptions for patients without cancer. Lastly, the TIRF-REMS was associated with a 22.5% level decline in the percentage of TIRF prescriptions for patients without known opioid tolerance (95% CI, -36.1% to -5.95%; P = .01) followed by 1.98% monthly decreases (95% CI, -3.19% to -0.80%; P = .001). Conclusions and Relevance: Implementation of the TIRF-REMS Access Program, a restrictive drug distribution program, was associated with a temporary reduction in the rate of TIRF prescribing to Medicare Part D beneficiaries, and with a sustained decrease in the percentage of TIRF prescriptions for patients without known opioid tolerance. Implementation may have also been associated with a temporary decrease in the percentage of TIRF prescriptions for patients without cancer.

Financial Relationships between Urologists and Industry: An Analysis of Open Payments Data.

INTRODUCTION: The Open Payments Program was enacted to increase transparency of financial relationships between physicians and the medical device and pharmaceutical industry. We examined nonresearch related financial relationships between urologists and industry in the United States using the latest Open Payments data. METHODS: We performed a descriptive analysis of Open Payments data released by the Centers for Medicare and Medicaid Services for 2014. Total payment amounts associated with various urological drug and device categories were calculated. We then examined for correlations between payments and prescribing at the national level using Medicare Part D prescribing data. RESULTS: There were 232,207 payments totaling $32,418,618 made to 8,618 urologists (73.6% of practicing urologists in the United States) during calendar year 2014. Median payment was $15 (IQR $11 to $24). While the majority of individual payments (68%) were $20 or less, 82% of the urologists in the database received more than $100 from industry during 2014. The frequency of industry payments was positively correlated with Medicare Part D prescribing frequency as well as the sum of claims (r = 0.726, p = 0.005 and r = 0.755, p = 0.003, respectively). CONCLUSIONS: Nearly 75% of urologists in United States received nonresearch payments from industry in 2014. Most individual payments were for less than $20 but the majority of urologists received more than $100 in aggregate during the study year, with most of the money going toward speaker fees. Payments were positively correlated with Part D prescribing, yet confounding variables make it difficult to establish a cause and effect relationship.

Emergency Department Visits Without Hospitalization Are Associated With Functional Decline in Older Persons.

STUDY OBJECTIVE: Among older persons, disability and functional decline are associated with increased mortality, institutionalization, and costs. The aim of the study was to determine whether illnesses and injuries leading to an emergency department (ED) visit but not hospitalization are associated with functional decline among community-living older persons. METHODS: From a cohort of 754 community-living older persons who have been followed with monthly interviews for up to 14 years, we matched 813 ED visits without hospitalization (ED only) to 813 observations without an ED visit or hospitalization (control). We compared the course of disability during the following 6 months between the 2 matched groups. To establish a frame of reference, we also compared the ED-only group with an unmatched group who were hospitalized after an ED visit (ED-hospitalized). Disability scores (range 0 [lowest] to 13 [highest]) were compared using generalized linear models adjusted for relevant covariates. Admission to a nursing home and mortality were evaluated as secondary outcomes. RESULTS: The ED-only and control groups were well matched. For both groups, the mean age was 84 years, and 69% were women. The baseline disability scores were 3.4 and 3.6 in the ED-only and control groups, respectively. During the 6-month follow-up period, the ED-only group had significantly higher disability scores than the control group, with an adjusted risk ratio of 1.14 (95% confidence interval [CI] 1.09 to 1.19). Compared with participants in the ED-only group, those who were hospitalized after an ED visit had disability scores that were significantly higher (risk ratio 1.17; 95% CI 1.12 to 1.22). Both nursing home admissions (hazard ratio 3.11; 95% CI 2.05 to 4.72) and mortality (hazard ratio 1.93; 95% CI 1.07 to 3.49) were higher in the ED-only group versus control group during the 6-month follow-up period. CONCLUSION: Although not as debilitating as an acute hospitalization, illnesses and injuries leading to an ED visit without hospitalization were associated with a clinically meaningful decline in functional status during the following 6 months, suggesting that the period after an ED visit represents a vulnerable time for community-living older persons.

Study: Older Patients Vulnerable to Functional Decline Following ED Visit.

A new study suggests older patients are particularly vulnerable to functional decline in the six months following a visit to the ED. Investigators noted the findings suggest there are opportunities to short-circuit this trajectory with added assessment and arrangements for follow-up interventions at the time of the ED visit. . Investigators compared 754 older patients who visited the ED with a matched group of 813 patients who did not visit an ED. They also studied an unmatched group of older patients who were hospitalized following an ED visit. . At the beginning of the study, both the ED-visit and control groups exhibited similar functional abilities, with levels of disability ranging between 3 and 4 on a disability scale, where lower scores represented lower levels of disability. . The ED-visit group scored an average of 14% higher than the control group participants on the disability scale during the six months following the ED visit. The group with participants who had ED visits followed by hospitalization demonstrated disability scores that were 17% higher than the ED-visit only group. . Investigators pointed to studies showing that ED-based screening and follow-up of older patients can prevent the risk of functional decline, decrease readmissions, and potentially prevent admissions to the ICU.

Association between payments from manufacturers of pharmaceuticals to physicians and regional prescribing: cross sectional ecological study.

OBJECTIVE:  To examine the association between payments made by the manufacturers of pharmaceuticals to physicians and prescribing by physicians within hospital referral regions. DESIGN:  Cross sectional analysis of 2013 and 2014 Open Payments and Medicare Part D prescribing data for two classes of commonly prescribed, commonly marketed drugs: oral anticoagulants and non-insulin diabetes drugs, overall and stratified by physician and payment type. SETTING:  306 hospital referral regions, United States. PARTICIPANTS:  45 949 454 Medicare Part D prescriptions written by 623 886 physicians to 10 513 173 patients for two drug classes: oral anticoagulants and non-insulin diabetes drugs. MAIN OUTCOME MEASURES:  Proportion, or market share, of marketed oral anticoagulants and non-insulin diabetes drugs prescribed by physicians among all drugs in each class and within hospital referral regions. RESULTS:  Among 306 hospital referral regions, there were 977 407 payments to physicians totaling $61 026 140 (£46 174 600; €54 632 500) related to oral anticoagulants, and 1 787 884 payments totaling $108 417 616 related to non-insulin diabetes drugs. The median market share of the hospital referral regions was 21.6% for marketed oral anticoagulants and 12.6% for marketed non-insulin diabetes drugs. Among hospital referral regions, one additional payment (median value $13, interquartile range, $10-$18) was associated with 94 (95% confidence interval 76 to 112) additional days filled of marketed oral anticoagulants and 107 (89 to 125) additional days filled of marketed non-insulin diabetes drugs (P<0.001). Payments to specialists were associated with greater prescribing of marketed drugs than payments to non-specialists (212 v 100 additional days filled per payment of marketed oral anticoagulants, 331 v 114 for marketed non-insulin diabetes drugs, P<0.001). Payments for speaker and consulting fees for non-insulin diabetes drugs were associated with greater prescribing of marketed drugs than payments for food and beverages or educational materials (484 v 110, P<0.001). CONCLUSIONS AND STUDY LIMITATIONS:  Payments by the manufacturers of pharmaceuticals to physicians were associated with greater regional prescribing of marketed drugs among Medicare Part D beneficiaries. Payments to specialists and payments for speaker and consulting fees were predominantly associated with greater regional prescribing of marketed drugs than payments to non-specialists or payments for food and beverages, gifts, or educational materials. As a cross sectional, ecological study, we cannot prove causation between payments to physicians and increased prescribing. Furthermore, our findings should be interpreted only at the regional level. Our study is limited to prescribing by physicians and the two drug classes studied.

Industry Relationships With Pediatricians: Findings From the Open Payments Sunshine Act.

BACKGROUND AND OBJECTIVES: Ties between physicians and pharmaceutical/medical device manufactures have received considerable attention. The Open Payments program, part of the Affordable Care Act, requires public reporting of payments to physicians from industry. We sought to describe payments from industry to physicians caring for children by (1) comparing payments to pediatricians to other medical specialties, (2) determining variation in payments among pediatric subspecialties, and (3) identifying the types of payment and the products associated with payments to pediatricians. METHODS: We conducted a descriptive, cross-sectional analysis of Open Payments data from January 1 to December 31, 2014. The primary outcomes included percent of physicians receiving payments, median total pay per physician, the types of payments received, and the drugs and devices associated with payments. RESULTS: There were 9 638 825 payments to physicians, totaling $1 186 217 157. There were 244 915 payments to general pediatricians and pediatric subspecialists, totaling >$32 million. The median individual payment to general pediatricians was $14.63 (interquartile range 12-20), and median total pay per general pediatrician was $89 (interquartile range 32-186). General pediatricians accounted for 1.7% of total payments, and 0.9% of the sum of payments. Developmental pediatricians had the highest percentage of pediatric physicians receiving payment, and pediatric endocrinologists received the highest median payment. Top marketed medications were for attention-deficient/hyperactivity disorder and vaccinations. CONCLUSIONS: More than 40% of pediatricians received payments from industry in 2014, a lower percentage than family physicians or internists. There was considerable variation in physician-industry ties among the pediatric subspecialties. Most payments were associated with medications that treat attention-deficient/hyperactivity disorder and vaccinations.

The Association Between Physician Empathy and Variation in Imaging Use.

BACKGROUND: Variation in emergency physician computed tomography (CT) imaging utilization is well described, but little is known about what drives it. Physician empathy has been proposed as a potential characteristic affecting CT utilization. OBJECTIVES: The objective was to describe empathy in a cohort of emergency physicians and evaluate its association with CT utilization. We also sought to compare emergency physician performance on an empathy psychometric test with performance on other psychometric tests previously proposed as predictors of CT utilization. METHODS: This cross-sectional study included two parts: 1) a secondary analysis of emergency department (ED) CT imaging utilization data in a large health system from July 2013 to June 2014 and 2) a survey study of the cohort of physicians responsible for this imaging using four psychometric scales: the Jefferson Scale of Empathy (JSE), a risk-taking subset of the Jackson Personality Index (RTS), the Stress from Uncertainty Scale (SUS), and the Malpractice Fear Scale (MFS). The study included data and physicians from four EDs: one urban, academic ED, two community, and one free-standing. A hierarchical, mixed-effects regression model was used to evaluate the association between emergency physician performance on the four scales and risk-adjusted CT imaging utilization. The model incorporated physician-specific CT utilization rates adjusted for propensity scores that were calculated using over 500 patient-level variables via random forest methods, physician demographics, and a random provider effect to account for the clustering of observations. RESULTS: CT variation analysis included 113,517 patients seen during the study period by the 74 eligible emergency physician survey respondents; 20,972 (18.5%) of these patients had at least one CT. The survey response rate was 74 of 82 (90.2%). Correlation coefficients between JSE and the other scales were not statistically significant. In subset analysis, there was a trend toward a physician's number of years in practice and RTS score contributing to CT utilization for traumatic head CT. There were no significant associations between performance on any of the psychometric scales and CT utilization. CONCLUSIONS: Performance on the JSE, RTS, SUS, or MFS was not predictive of risk-adjusted CT utilization in the ED. The underlying physician-based factors that mediate interphysician variation remain to be clearly identified.

Financial Ties Between Emergency Physicians and Industry: Insights From Open Payments Data.

STUDY OBJECTIVE: The Open Payments program requires reporting of payments by medical product companies to teaching hospitals and licensed physicians. We seek to describe nonresearch, nonroyalty payments made to emergency physicians in the United States. METHODS: We performed a descriptive analysis of the most recent Open Payments data released to the public by the Centers for Medicare & Medicaid Services covering the 2014 calendar year. We calculated the median payment, the total pay per physician, the types of payments, and the drugs and devices associated with payments to emergency physicians. For context, we also calculated total pay per physician and the percentage of active physicians receiving payments for all specialties. RESULTS: There were 46,405 payments totaling $10,693,310 to 12,883 emergency physicians, representing 30% of active emergency physicians in 2013. The percentage of active physicians within a specialty who received a payment ranged from 14.6% in preventive medicine to 91% in orthopedic surgery. The median payment and median total pay to emergency physicians were $16 (interquartile range $12 to $68) and $44 (interquartile range $16 to $123), respectively. The majority of payments (83%) were less than $100. Food and beverage (86%) was the most frequent type of payment. The most common products associated with payments to emergency physicians were rivaroxaban, apixaban, ticagrelor, ceftaroline, canagliflozin, dabigatran, and alteplase. CONCLUSION: Nearly a third of emergency physicians received nonresearch, nonroyalty payments from industry in 2014. Most payments were of small monetary value and for activities related to the marketing of antithrombotic drugs.

Prediction of In-hospital Mortality in Emergency Department Patients With Sepsis: A Local Big Data-Driven, Machine Learning Approach.

OBJECTIVES: Predictive analytics in emergency care has mostly been limited to the use of clinical decision rules (CDRs) in the form of simple heuristics and scoring systems. In the development of CDRs, limitations in analytic methods and concerns with usability have generally constrained models to a preselected small set of variables judged to be clinically relevant and to rules that are easily calculated. Furthermore, CDRs frequently suffer from questions of generalizability, take years to develop, and lack the ability to be updated as new information becomes available. Newer analytic and machine learning techniques capable of harnessing the large number of variables that are already available through electronic health records (EHRs) may better predict patient outcomes and facilitate automation and deployment within clinical decision support systems. In this proof-of-concept study, a local, big data-driven, machine learning approach is compared to existing CDRs and traditional analytic methods using the prediction of sepsis in-hospital mortality as the use case. METHODS: This was a retrospective study of adult ED visits admitted to the hospital meeting criteria for sepsis from October 2013 to October 2014. Sepsis was defined as meeting criteria for systemic inflammatory response syndrome with an infectious admitting diagnosis in the ED. ED visits were randomly partitioned into an 80%/20% split for training and validation. A random forest model (machine learning approach) was constructed using over 500 clinical variables from data available within the EHRs of four hospitals to predict in-hospital mortality. The machine learning prediction model was then compared to a classification and regression tree (CART) model, logistic regression model, and previously developed prediction tools on the validation data set using area under the receiver operating characteristic curve (AUC) and chi-square statistics. RESULTS: There were 5,278 visits among 4,676 unique patients who met criteria for sepsis. Of the 4,222 patients in the training group, 210 (5.0%) died during hospitalization, and of the 1,056 patients in the validation group, 50 (4.7%) died during hospitalization. The AUCs with 95% confidence intervals (CIs) for the different models were as follows: random forest model, 0.86 (95% CI = 0.82 to 0.90); CART model, 0.69 (95% CI = 0.62 to 0.77); logistic regression model, 0.76 (95% CI = 0.69 to 0.82); CURB-65, 0.73 (95% CI = 0.67 to 0.80); MEDS, 0.71 (95% CI = 0.63 to 0.77); and mREMS, 0.72 (95% CI = 0.65 to 0.79). The random forest model AUC was statistically different from all other models (p ≤ 0.003 for all comparisons). CONCLUSIONS: In this proof-of-concept study, a local big data-driven, machine learning approach outperformed existing CDRs as well as traditional analytic techniques for predicting in-hospital mortality of ED patients with sepsis. Future research should prospectively evaluate the effectiveness of this approach and whether it translates into improved clinical outcomes for high-risk sepsis patients. The methods developed serve as an example of a new model for predictive analytics in emergency care that can be automated, applied to other clinical outcomes of interest, and deployed in EHRs to enable locally relevant clinical predictions.

Improving emergency physician performance using audit and feedback: a systematic review.

BACKGROUND: Audit and feedback can decrease variation and improve the quality of care in a variety of health care settings. There is a growing literature on audit and feedback in the emergency department (ED) setting. Because most studies have been small and not focused on a single clinical process, systematic assessment could determine the effectiveness of audit and feedback interventions in the ED and which specific characteristics improve the quality of emergency care. OBJECTIVE: The objective of the study is to assess the effect of audit and feedback on emergency physician performance and identify features critical to success. METHODS: We adhered to the PRISMA statement to conduct a systematic review of the literature from January 1994 to January 2014 related to audit and feedback of physicians in the ED. We searched Medline, EMBASE, PsycINFO, and PubMed databases. We included studies that were conducted in the ED and reported quantitative outcomes with interventions using both audit and feedback. For included studies, 2 reviewers independently assessed methodological quality using the validated Downs and Black checklist for nonrandomized studies. Treatment effect and heterogeneity were to be reported via meta-analysis and the I2 inconsistency index. RESULTS: The search yielded 4332 articles, all of which underwent title review; 780 abstracts and 131 full-text articles were reviewed. Of these, 24 studies met inclusion criteria with an average Downs and Black score of 15.6 of 30 (range, 6-22). Improved performance was reported in 23 of the 24 studies. Six studies reported sufficient outcome data to conduct summary analysis. Pooled data from studies that included 41,124 patients yielded an average treatment effect among physicians of 36% (SD, 16%) with high heterogeneity (I2=83%). CONCLUSION: The literature on audit and feedback in the ED reports positive results for interventions across numerous clinical conditions but without standardized reporting sufficient for meta-analysis. Characteristics of audit and feedback interventions that were used in a majority of studies were feedback that targeted errors of omission and that was explicit with measurable instruction and a plan for change delivered in the clinical setting greater than 1 week after the audited performance using a combination of media and types at both the individual and group levels. Future work should use standardized reporting to identify the specific aspects of audit or feedback that drive effectiveness in the ED.

The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates.

OBJECTIVES: For patients in whom acute coronary syndrome (ACS) is a concern, disposition decisions are complex and multifactorial and have traditionally been a source of considerable variation. An important factor in disposition decisions for these patients may be physician-perceived medicolegal risk and related professional concerns. The study aim was to determine, at the point of care, how much less frequently physicians report that they would admit possible ACS patients if there was either zero or a defined medicolegal risk. METHODS: This was a point-of-care emergency physician survey. Research assistants approached physicians at or immediately following the moment of disposition decisions for patients who were being admitted for ACS. The primary outcome measures were the proportion of physicians reporting that patients would not have been admitted if medicolegal issues were of no concern and the proportion of physicians reporting that patients would not have been admitted if there was an "acceptable miss rate" of 1% to 2% for ACS patients. RESULTS: During the 3-month study period, 576 patients were admitted to an inpatient unit or to the ED observation protocol. Physicians were approached in 271 cases, and 259 surveys were completed. When presented with hypothetical zero medicolegal risk, physicians answered that they would not have admitted the patients in 30% of cases. With a hypothetical 1% to 2% acceptable miss rate, physicians indicated that they would not have admitted the patients in 29% of the cases. CONCLUSIONS: ED medicolegal and professional concerns may substantially increase admissions for possible ACS. An acceptable miss rate or a zero medicolegal risk environment could potentially lead to a major reduction in admissions that physicians feel to be clinically unnecessary.

The visit-data warehouse: enabling novel secondary use of health information exchange data.

INTRODUCTION/OBJECTIVES: Health Information Exchange (HIE) efforts face challenges with data quality and performance, and this becomes especially problematic when data is leveraged for uses beyond primary clinical use. We describe a secondary data infrastructure focusing on patient-encounter, nonclinical data that was built on top of a functioning HIE platform to support novel secondary data uses and prevent potentially negative impacts these uses might have otherwise had on HIE system performance. BACKGROUND: HIE efforts have generally formed for the primary clinical use of individual clinical providers searching for data on individual patients under their care, but many secondary uses have been proposed and are being piloted to support care management, quality improvement, and public health. DESCRIPTION OF THE HIE AND BASE INFRASTRUCTURE: This infrastructure review describes a module built into the Healthix HIE. Healthix, based in the New York metropolitan region, comprises 107 participating organizations with 29,946 acute-care beds in 383 facilities, and includes more than 9.2 million unique patients. The primary infrastructure is based on the InterSystems proprietary Caché data model distributed across servers in multiple locations, and uses a master patient index to link individual patients' records across multiple sites. We built a parallel platform, the "visit data warehouse," of patient encounter data (demographics, date, time, and type of visit) using a relational database model to allow accessibility using standard database tools and flexibility for developing secondary data use cases. These four secondary use cases include the following: (1) tracking encounter-based metrics in a newly established geriatric emergency department (ED), (2) creating a dashboard to provide a visual display as well as a tabular output of near-real-time de-identified encounter data from the data warehouse, (3) tracking frequent ED users as part of a regional-approach to case management intervention, and (4) improving an existing quality improvement program that analyzes patients with return visits to EDs within 72 hours of discharge. RESULTS/LESSONS LEARNED: Setting up a separate, near-real-time, encounters-based relational database to complement an HIE built on a hierarchical database is feasible, and may be necessary to support many secondary uses of HIE data. As of November 2014, the visit-data warehouse (VDW) built by Healthix is undergoing technical validation testing and updates on an hourly basis. We had to address data integrity issues with both nonstandard and missing HL7 messages because of varied HL7 implementation across the HIE. Also, given our HIEs federated structure, some sites expressed concerns regarding data centralization for the VDW. An established and stable HIE governance structure was critical in overcoming this initial reluctance. CONCLUSIONS: As secondary use of HIE data becomes more prevalent, it may be increasingly necessary to build separate infrastructure to support secondary use without compromising performance. More research is needed to determine optimal ways of building such infrastructure and validating its use for secondary purposes.

Health information exchange improves identification of frequent emergency department users.

We hypothesized that using communitywide data from a health information exchange (HIE) could improve the ability to identify frequent emergency department (ED) users-those with four or more ED visits in thirty days-by allowing ED use to be measured across unaffiliated hospitals. When we analyzed HIE-wide data instead of site-specific data, we identified 20.3 percent more frequent ED users (5,756 versus 4,785) and 16.0 percent more visits by them to the ED (53,031 versus 45,771). Additionally, we found that 28.8 percent of frequent ED users visited multiple EDs during the twelve-month study period, versus 3.0 percent of all ED users. All three differences were significant ($$p ). An improved ability to identify frequent ED users allows better targeting of case management and other services that can improve frequent ED users' health and reduce their use of costly emergency medical services.

Effect of renal function loss on NT-proBNP level variations.

OBJECTIVE: NT-proBNP level is used for the detection of acute CHF and as a predictor of survival. However, a number of factors, including renal function, may affect the NT-proBNP levels. This study aims to provide a more precise way of interpreting NT-proBNP levels based on GFR, independent of age. METHODS: This study includes 247 pts in whom CHF and known confounders of elevated NT-proBNP were excluded, to show the relationship of GFR in association with age. The effect of eGFR on NT-proBNP level was adjusted by dividing 1000 x log(NT-proBNP) by eGFR then further adjusting for age in order to determine a normalized NT-proBNP value. RESULTS: The normalized NT-proBNP levels were affected by eGFR independent of the age of the patient. CONCLUSION: A normalizing function based on eGFR eliminates the need for an age-based reference ranges for NT-proBNP.