Why Veterans Choose VA Versus non-VA Emergency Care: A Qualitative Study.

INTRODUCTION: In ensuring the timely delivery of emergency care to Veterans, Veterans Affairs (VA) offers both emergency care services in its own facilities and, increasingly, purchases care for Veterans in non-VA (community) emergency department (ED) settings. Although in recent years emergency care coverage has become the single largest contributor to VA community care spending, no study to date has examined Veteran decision-making as it relates to ED setting choice. The purpose of this study is to identify and describe reasons why Veterans choose VA versus non-VA emergency care settings. MATERIALS AND METHODS: Veterans Health Administration data were used to identify geographically diverse Veterans who recently used emergency care. We conducted semi-structured telephone interviews from December 2018 through March 2020 with 50 Veterans to understand the factors Veterans consider when deciding where to obtain ED care. Interviews were audio-recorded and transcribed verbatim. We conducted a directed content analysis of interview transcripts and developed a matrix to summarize and categorize each Veteran's decision-making process to compare participants and to identify common patterns. RESULTS: When choosing between VA and non-VA-EDs, Veterans described 3 distinct patterns of decision-making: (1) choosing the closest ED (often community) for acute conditions; (2) traveling farther for VA care due to preference and financial coverage; and (3) selecting VA when both types of ED care were equidistant. Perceptions of community resources, condition-specific needs, financial considerations, and personal preferences dominated the decision-making. For example, most Veterans (74%) rated their acuity as high, and self-perceived severity/urgency of their condition was the most cited factor influencing where Veterans decided to go for ED care. CONCLUSIONS: Our qualitative results help provide insight into how and why Veterans choose to seek emergency care. As the number of Veterans treated in non-VA EDs continues to rise, VA and non-VA ED providers as well as policy makers may benefit from understanding the challenges Veterans face when making this decision.

Patient Safety Indicators at an Academic Veterans Affairs Hospital: Addressing Dual Goals of Clinical Care and Validity.

BACKGROUND: Hospital-acquired complications add to patient morbidity and mortality, costs, length of stay, and negative patient experience. Patient Safety Indicators (PSIs) are a validated and widely used metric to evaluate hospital administrative data on preventing these events. Although many studies have addressed PSI validity, few have aimed to reduce PSI through clinical care. The authors aimed to reduce PSI events by addressing both validity and clinical care. METHODS: Frontline clinicians used a deep dive template to provide input on all PSI cases, which were then reviewed by a PSI task force to identify performance gaps. After analyzing the frequency of gaps and cost-vs.-impact of potential solutions, five interventions were implemented to address the three most common, highly weighted PSIs: pressure ulcers, postoperative venous thromboembolism (VTE), and postoperative sepsis. Clinical care interventions included increasing patient mobility by creating a specialized mobility technician position, skin care audits to prevent pressure ulcers, and increasing use of pharmacologic VTE prophylaxis. Administrative interventions addressed improving clinician-coding concordance for sepsis and increasing documentation of comorbidities. RESULTS: After interventions, the number of PSI events for composite PSI, VTE, and sepsis decreased by 41.3% (p = 0.039), 85.2% (p = 0.0091), and 51.5% (p = 0.063), respectively, relative to the preintervention period. Pressure ulcers increased by 33.3% (p = 0.0091). CONCLUSION: Hospital complications cause substantial burden to hospitals, patients, and caregivers. Addressing administrative and clinical factors with targeted interventions led to reduction in composite PSI. Further efforts are needed locally to reduce the pressure ulcer PSI.

Emergency Department Use Among Combat and Non-Combat Post-9/11 Military Veterans.

INTRODUCTION: Most post-9/11 Veterans have completed at least 1 combat deployment-a known factor associated with adverse health outcomes. Such Veterans are known to have unmet health care needs, and the emergency department (ED) may serve as a safety net, yet little is known about whether combat status is associated with more frequent ED use. We sought to evaluate the relationship between combat status and frequency of ED use among post-9/11 Veterans and assess the most common reasons for ED visits. MATERIALS AND METHODS: This retrospective cohort study consisted of post-9/11 Veterans who enrolled in U.S. Department of Veterans Affairs (VA) care between fiscal years (FYs) 2005 and 2015. Data were obtained from the VA Corporate Data Warehouse. Incidence rates for ED visits for combat and non-combat Veterans were compared from FY 2010 to 2019 using zero-inflated negative binomial regression. The most frequent reasons for ED visits were determined using International Classification of Diseases codes. This study was approved by the Stanford Institutional Review Board. RESULTS: Among 1.3 million Veterans included in analyses, 70.4% had deployed to a combat zone. The mean (SD) age of our cohort was 32.6 (5.0) years and 83.5% of Veterans were male. After controlling for other factors, combat Veterans had 1.84 times the rate of ED visits compared to non-combat Veterans (95% CI, 1.83-1.85). Only combat Veterans had a mental health-related ED visit (suicidal ideations) among the top 3 reasons for ED presentation. CONCLUSIONS: Those who deployed to a combat zone had a significantly higher rate of ED use compared to those who did not. Further, mental health-related ED diagnoses appeared to be more prevalent in combat Veterans. These findings highlight the unique health care needs faced by combat Veterans and emphasize the importance of tailored interventions and support services for this specific population.

Community Emergency Care Use by Veterans in an Era of Expanding Choice.

Importance: Recently passed legislation aimed at improving access to care has considerably expanded options for veterans to receive emergency care in community, or non-Veterans Affairs (VA) settings. However, national trends in community emergency department (ED) use by veterans are unknown. Objective: To examine national, temporal trends in the frequencies and types of ED visits provided in community settings and explore the association between facilities' purchase of community care with facility and regional characteristics. Design, Setting, and Participants: Retrospective, observational cross-sectional study of ED visits over fiscal years (FY) 2016 to 2022. VA and community ED encounter data were obtained from the VA Corporate Data Warehouse and the Office of Integrated Veteran Care. Participants were veterans receiving ED care at VA facilities or paid for by the VA in the community. Data were analyzed from June to September 2023. Main Outcomes and Measures: The primary outcome measures included community ED visit volume, disposition, and payments over time. Also, the most common and costly ED visits were assessed. Negative binomial regression analysis examined associations between facility and regional characteristics and the rate of ED visits purchased in community settings relative to all ED visits. Results: There were 19 787 056 ED visits, predominantly at VA facilities (14 532 261 visits [73.4%]), made by 3 972 503 unique veterans from FY 2016 to 2022. The majority of ED users were male (3 576 120 individuals [90.0%]), and the median (IQR) age was 63 (48-73) years. The proportion of community ED visits increased in absolute terms from 18% in FY 2016 to 37% in FY 2022. Total community ED payments, adjusted to 2021 dollars, were $1.18 billion in FY 2016 and over $6.14 billion in FY 2022. The most common reasons for ED visits in the community were for nonspecific chest pain (305 082 visits [6%]), abdominal pain (174 836 visits [3%]), and septicemia (149 968 visits [3%]). The average proportion of ED visits purchased by a VA facility increased from 14% in FY 2016 to 32% by FY 2022. In multivariable analyses, facilities with greater ED volume and low-complexity facilities had higher expected rates of community emergency care than lower volume and high-complexity facilities, respectively. Conclusions and Relevance: As veterans increasingly use community EDs for acute, unscheduled needs, attention to factors associated with veterans' use of acute care services in different settings are important to identify access barriers and to ensure veterans' health care needs are met.

Research and policy recommendations from the SOTA XVI: State of the Art Conference on VA Emergency Medicine.

To better understand and prioritize research on emergency care for Veterans, the Department of Veteran Affairs (VA) Health Services Research and Development convened the 16th State of the Art Conference on VA Emergency Medicine (SAVE) in Winter 2022 with emergency clinicians, researchers, operational leaders, and additional stakeholders in attendance. Three specific areas of focus were identified including older Veterans, Veterans with mental health needs, and emergency care in the community (non-VA) settings. Among older Veterans, identified priorities included examination of variation in care and its impact on patient outcomes, utilization, and costs; quality of emergency department (ED) care transitions and strategies to improve them; impact of geriatric ED care improvement initiatives; and use of geriatric assessment tools in the ED. For Veterans with mental health needs, priorities included enhancing the reach of effective, multicomponent suicide prevention interventions; development and evaluation of interventions to manage substance use disorders; and identifying and examining safety and effective acute psychosis practices. Community (non-VA) emergency care priorities included examining changes in patterns of use and costs in VA and the community care settings as a result of recent policy and coverage changes (with an emphasis on modifiable factors); understanding quality, safety, and Veteran experience differences between VA and community settings; and better understanding follow-up needs among Veterans who received emergency care (or urgent care) and how well those needs are being coordinated, communicated, and met. Beyond these three groups, cross-cutting themes included the use of telehealth and implementation science to refine multicomponent interventions, care coordination, and data needs from both VA and non-VA sources. Findings from this conference will be disseminated through multiple mechanisms and contribute to future funding applications focused on improving Veteran health.

Emergency department utilization and presenting chief complaints by Veterans living with dementia.

OBJECTIVES: Veteran persons living with dementia (PLWDs) have high acute care utilization. We aim to understand why PLWDs seek care in the emergency department (ED) and how their utilization differs from older Veterans with no dementia diagnosis. We demonstrate the use of a novel national chief complaint data set in the Veteran Affairs Health Care System. METHODS: This was a retrospective observational study of ED users 65 years or older as of FY2017. The primary outcome is presence of one or more ED visits in FYs 2017-2018 using a logistic regression model controlling for dementia and other variables. Secondary outcomes include counts of ED visits by disposition, Emergency Severity Index, chief complaints defined by a natural language processing program, and ED encounter diagnoses defined by primary International Statistical Classification of Diseases, Tenth Revision (ICD-10-CM) code. RESULTS: Our cohort of Veterans comprised 3,115,263 patients. Of those, 255,372 (8.2%) had a diagnosis of dementia. Logistic regression modeling demonstrated that dementia is a significant predictor of ED use (p < 0.0001), with PLWDs more likely to have an ED visit (odds ratio 1.96, 95% confidence interval 1.94-1.98). PLWDs were admitted at higher rates when accounting for age and acuity. Chief complaints that were more common among PLWDs included falls (6.7% dementia vs. 3.3% without dementia), weakness (3.6% vs. 2.2%), and abnormal mental state (2.2% vs. 0.4%). ICD-10-CM codes were largely similar between the two groups. CONCLUSIONS: Our results reinforce that the ED is a common access point for Veterans with dementia. These patients require special consideration as they are more likely to visit the ED and be admitted. Our use of a novel national chief complaint data set suggests that they more commonly present with certain geriatric syndromes and nonspecific complaints. Further work is needed to determine whether these would warrant targeted interventions to improve quality of acute care.

Hospital-level variation in risk-standardized admission rates for emergency care-sensitive conditions among older and younger Veterans.

OBJECTIVES: Research examining emergency department (ED) admission practices within the Department of Veterans Affairs (VA) is limited. This study investigates facility-level variation in risk-standardized admission rates (RSARs) for emergency care-sensitive conditions (ECSCs) among older (≥65 years) and younger (<65 years) Veterans across VA EDs. METHODS: Veterans presenting to a VA ED for an ECSC between October 1, 2016 and September 30, 2019 were identified and the 10 most common ECSCs established. ECSC-specific RSARs were calculated using hierarchical generalized linear models, adjusting for Veteran and encounter characteristics. The interquartile range ratio (IQR ratio) and coefficient of variation were measures of dispersion for each condition and were stratified by age group. Associations with facility characteristics were also examined in condition-specific multivariable models. RESULTS: The overall cohort included 651,336 ED visits across 110 VA facilities for the 10 most common ECSCs-chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, volume depletion, tachyarrhythmias, acute diabetes mellitus, gastrointestinal (GI) bleeding, asthma, sepsis, and myocardial infarction (MI). After adjusting for case mix, the ECSCs with the greatest variation (IQR ratio, coefficient of variation) in RSARs were asthma (1.43, 32.12), COPD (1.39, 24.64), volume depletion (1.38, 23.67), and acute diabetes mellitus (1.28, 17.52), whereas those with the least variation were MI (1.01, 0.87) and sepsis (1.02, 2.41). Condition-specific RSARs were not qualitatively different between age subgroups. Association with facility characteristics varied across ECSCs and within condition-specific age subgroups. CONCLUSIONS: We identified unexplained facility-level variation in RSARs for Veterans presenting with the 10 most common ECSCs to VA EDs. The magnitude of variation did not appear to be qualitatively different between older and younger Veteran subgroups. Variation in RSARs for ECSCs may be an important target for systems-based levers to improve value in VA emergency care.

Veterans' Experiences With Accessing Community Emergency Care.

INTRODUCTION: Under current regulations, there are three separate authorities for which the Veterans Health Administration (VHA) can pay for emergency medical care received by Veterans in the community. The three VHA authorities have overlapping criteria and eligibility requirements that contribute to a complex and confusing landscape for Veterans when they obtain emergency care in the community. Given the intricacies in how VHA provides coverage for community emergency care and the desire to provide seamless Veteran-centric care, it is imperative to understand Veterans' experiences with navigating coverage for community emergency care. The purpose of this study was to elicit feedback from Veterans about their experiences with and perceptions of community emergency care coverage paid for by VHA. MATERIALS AND METHODS: Veterans Health Administration data were used to identify geographically diverse Veterans who recently used emergency care. We conducted semi-structured, qualitative interviews with 50 Veterans to understand their VHA coverage and experiences with accessing community emergency care. Interviews were audio recorded and transcribed verbatim. We conducted directed content analysis of interview transcripts. RESULTS: Veterans emphasized three major concerns with navigating community emergency care: (1) they lack information about benefits and eligibility when they need it most, (2) they require assistance with medical billing to avoid financial hardship and future delays in care, and (3) they desire multimodal communication about VHA policies or updates in emergency coverage. CONCLUSIONS: Our results highlight the challenges Veterans experience in understanding VHA coverage for community emergency care. Feedback suggests that improving information, support, and communication may help Veterans make timely, informed decisions when experiencing unexpected illness or injury.

Engaging Patients in the Veterans Health Administration's Lean Enterprise Transformation: A Qualitative Study.

BACKGROUND AND OBJECTIVES: Lean management is a strategy for improving health care experiences of patients. While best practices for engaging patients in quality improvement have solidified in recent years, few reports specifically address patient engagement in Lean activities. This study examines the benefits and challenges of incorporating patient engagement strategies into the Veterans Health Administration's (VA) Lean transformation. METHODS: We conducted a multisite, mixed-methods evaluation of Lean deployment at 10 VA medical facilities, including 227 semistructured interviews with stakeholders, including patients. RESULTS: Interviewees noted that a patient-engaged Lean approach is mutually beneficial to patients and health care employees. Benefits included understanding the veteran's point of view, uncovering inefficient aspects of care processes, improved employee participation in Lean events, increased transparency, and improved reputation for the organization. Challenges included a need for focused time and resources to optimize veteran participation, difficulty recruiting a diverse group of veteran stakeholders, and a lack of specific instructions to encourage meaningful participation of veterans. CONCLUSIONS/IMPLICATIONS: As the first study to focus on patient engagement in Lean transformation efforts at the VA, this study highlights ways to effectively partner with patients in Lean-based improvement efforts. Lessons learned may also help optimize patient input into quality improvement more generally.

Achieving transformation to lean management systems in health care.

OBJECTIVE: To understand what factors and organizational dynamics enable Lean transformation of health care organizations. DATA SOURCES: Primary data were collected through two waves of interviews in 2016-2017 with leaders and staff at seven veterans affairs medical centers participating in Lean enterprise transformation. STUDY DESIGN: Using an observational study design, for each site we coded and rated seven potential enablers of transformation. The outcome measure was the extent of Lean transformation, constructed by coding and rating 11 markers of depth and spread of transformation. Using multivalue coincidence analysis (CNA), we identified enablers that distinguished among sites having different levels of transformation. We identified representative quotes for the enablers. DATA COLLECTION METHODS: We interviewed 121 executive leaders, middle managers, expert consultants, systems redesign staff, frontline supervisors, and staff. PRINCIPAL FINDINGS: Two sites achieved high Lean transformation, three medium, and two low. Together leadership support and capability development were sufficient for the three-level Lean transformation outcomes with 100% consistency and 100% coverage. High scores on both corresponded to high Lean transformation; medium on either one corresponded to medium transformation; and low on both corresponded to low transformation. Additionally, low scores in communication and availability of data and very low scores in alignment characterized low-transformation sites. Sites with high leadership support also had a high veteran engagement. CONCLUSIONS: This multisite study develops a novel measure of the extent of organization-wide Lean transformation and uses CNA to identify enablers linked to transformation. It provides insights into why and how some organizations are more successful at transformation than others. Findings support the applicability of the organization transformation model that guided the study and highlight the roles of executive leadership and capability development in the dynamics of transformation.

Veterans' Use of Telehealth for Veterans Health Administration Community Care Urgent Care During the Early COVID-19 Pandemic.

BACKGROUND: Since the onset of the COVID-19 pandemic, telehealth has been an option for Veterans receiving urgent care through Veterans Health Administration Community Care (CC). OBJECTIVE: We assessed use, arrangements, Veteran decision-making, and experiences with CC urgent care delivered via telehealth. DESIGN: Convergent parallel mixed methods, combining multivariable regression analyses of claims data with semistructured Veteran interviews. SUBJECTS: Veterans residing in the Western United States and Hawaii, with CC urgent care claims March 1 to September 30, 2020. KEY RESULTS: In comparison to having in-person only visits, having a telehealth-only visit was more likely for Veterans who were non-Hispanic Black, were urban-dwelling, lived further from the clinic used, had a COVID-related visit, and did not require an in-person procedure. Predictors of having both telehealth and in-person (compared with in-person only) visits were other (non-White, non-Black) non-Hispanic race/ethnicity, urban-dwelling status, living further from the clinic used, and having had a COVID-related visit. Care arrangements varied widely; telephone-only care was common. Veteran decisions about using telehealth were driven by limitations in in-person care availability and COVID-related concerns. Veterans receiving care via telehealth generally reported high satisfaction. CONCLUSIONS: CC urgent care via telehealth played an important role in providing Veterans with care access early in the COVID-19 pandemic. Use of telehealth differed by Veteran characteristics; lack of in-person care availability was a driver. Future work should assess for changes in telehealth use with pandemic progression, geographic differences, and impact on care quality, care coordination, outcomes, and costs to ensure Veterans' optimal and equitable access to care.

The Veterans Health Administration (VHA) Innovators Network: Evaluation design, methods and lessons learned through an embedded research approach.

BACKGROUND: Collaboration between researchers, implementers and policymakers improves uptake of health systems research. In 2018, researchers and VHA Innovators Network (iNET) leadership used an embedded research model to conduct an evaluation of iNET. We describe our evaluation design, early results, and lessons learned. METHODS: This mixed-methods evaluation incorporated primary data collection via electronic survey, descriptive analysis using existing VA datasets (examining associations between facility characteristics and iNET participation), and qualitative interviews to support real-time program implementation and to probe perceived impacts, benefits and challenges of participation. RESULTS: We developed reporting tools and collected data regarding site participation, providing iNET leadership rapid access to needed information on projects (e.g., target populations reached, milestones achieved, and barriers encountered). Secondary data analyses indicated iNET membership was greater among larger, more complex VA facilities. Of the 37 iNET member sites, over half (n = 22) did not have any of the six major types of VA research centers; thus iNET is supporting VA sites not traditionally served by research innovation pathways. Qualitative findings highlighted enhanced engagement and perceived value of social and informational networks. CONCLUSIONS: Working alongside our iNET partners, we supported and influenced iNET's development through our embedded evaluation's preliminary findings. We also provided training and guidance aimed at building capacity among iNET participants. IMPLICATIONS: Embedded research can yield successful collaborative efforts between researchers and partners. An embedded research team can help programs pivot to ensure effective use of limited resources. Such models inform program development and expansion, supporting strategic planning and demonstrating value.

Community Urgent Care Use Following Implementation of the Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks Act.

BACKGROUND: Effective June 6, 2019, Veterans Affairs (VA) began offering a new urgent care (UC) benefit that provides eligible Veterans with greater choice and access to care for the treatment of minor injuries and illnesses in their local communities. OBJECTIVES: The aim was to describe trends in UC use, identify predictors of UC benefit use, and understand the factors associated with community UC use versus VA emergency department (ED) or urgent care center (UCC) use. STUDY DESIGN: Using VA administrative data, this was a retrospective cross-sectional study of Veterans that were enrolled in VA in FY19. Veterans were classified into 3 groups: UC benefit users, benefit non-users, and VA ED/UCC users. METHODS: We used summary statistics to compare population characteristics across user groups. To determine whether predisposing, enabling, and need factors predicted UC benefit use and setting choice (community UCC vs. VA ED/UCC), 2 logistic regression models were fitted to assess odds of UC use. RESULTS: From June 6, 2019 through February 29, 2020, 138,305 Veterans made 175,821 community UC visits. The majority of visits were made by White males who were not subject to co-pays. The average cost to VA for UC visits was $132 (SD=$135). Upper respiratory infections were the most common reason for UC use. Being younger, female, and living farther from a VA ED/UCC was associated with greater UC benefit use compared with both benefit non-users and VA ED/UCC users. CONCLUSIONS: The new benefit expands Veteran access to UC services for low-acuity conditions.

Short-term Effects of Canceled Elective Procedures Due to COVID-19: Evidence From the Veterans Affairs Healthcare System.

OBJECTIVE: To determine whether delayed or canceled elective procedures due to COVID-19 resulted in higher rates of ED utilization and/or increased mortality. SUMMARY OF BACKGROUND DATA: On March 15, 2020, the VA issued a nationwide order to temporarily pause elective cases due to COVID-19. The effects of this disruption on patient outcomes are not yet known. METHODS: This retrospective cohort study used data from the VA Corporate Data Warehouse. Surgical procedures canceled due to COVID-19 in 2020 (n = 3326) were matched to similar completed procedures in 2018 (n = 151,863) and 2019 (n = 146,582). Outcome measures included 30- and 90-day VA ED use and mortality in the period following the completed or canceled procedure. We used exact matching on surgical procedure category and nearest neighbor matching on patient characteristics, procedure year, and facility. RESULTS: Patients with elective surgical procedures canceled due to COVID-19 were no more likely to have an ED visit in the 30- [Difference: -4.3% pts; 95% confidence interval (CI): -0.078, -0.007] and 90 days (-0.9% pts; 95% CI: -0.068, 0.05) following the expected case date. Patients with cancellations had no difference in 30- (Difference: 0.1% pts; 95% CI: -0.008, 0.01) and 90-day (Difference: -0.4% pts; 95% CI: -0.016, 0.009) mortality rates when compared to similar patients with similar procedures that were completed in previous years. CONCLUSIONS: The pause in elective surgical cases was not associated with short-term adverse outcomes in VA hospitals, suggesting appropriate surgical case triage and management. Further study will be essential to determine if the delayed cases were associated with longer-term effects.

Facilitators and barriers to the Lean Enterprise Transformation program at the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration piloted a nationwide Lean Enterprise Transformation program to optimize delivery of services to patients for high value care. PURPOSE: Barriers and facilitators to Lean implementation were evaluated. METHODS: Guided by the Lean Enterprise Transformation evaluation model, 268 interviews were conducted, with stakeholders across 10 Veterans Health Administration medical centers. Interview transcripts were analyzed using thematic analysis techniques. RESULTS: Supporting the utility of the model, facilitators and barriers to Lean implementation were found in each of the Lean Enterprise Transformation evaluation model domains: (a) impetus to transform, (b) leadership commitment to quality, (c) improvement initiatives, (d) alignment across the organization, (e) integration across internal boundaries, (f) communication, (g) capability development, (h) informed decision making, (i) patient engagement, and (j) organization culture. In addition, three emergent themes were identified: staff engagement, sufficient staffing, and use of Lean experts (senseis). CONCLUSIONS: Effective implementation required staff engagement, strategic planning, proper scoping and pacing, deliberate coaching, and accountability structures. Visible, stable leadership drove Lean when leaders articulated a clear impetus to change, aligned goals within the facility, and supported middle management. Reliable data and metrics provided support for and evidence of successful change. Strategic early planning with continual reassessment translated into focused and sustained Lean implementation. PRACTICE IMPLICATIONS: Prominent best practices identified include (a) reward participants by broadcasting Lean successes; (b) provide time and resources for participation in Lean activities; (c) avoid overscoping projects; (d) select metrics that closely align with improvement processes; and (e) invest in coaches, informal champions, process improvement staff, and senior leadership to promote staff engagement and minimize turnover.

To Admit or Not to Admit: Emergency Department Discharges After Request for Medicine Admission.

BACKGROUND: The decision to discharge versus admit a patient from the emergency department (ED) carries significant consequences to the patient and healthcare system. METHODS: We evaluated all ED visits at a single facility from January 1-December 31, 2015, where the ED provider initially requested admission to medicine; however, following medicine evaluation, the patient was discharged from the ED. RESULTS: 8.1% of medicine referrals resulted in discharge from the ED after referral for admission. 62.6% lacked documentation by medicine or another consulting service. Patients completed clinic follow-up within 7 or 30 days, 52.8% and 76.0% respectively. Emergency department revisit rates were similar for patients not referred versus referred for admission (8.0% vs. 8.1%, 13.3% vs. 14.6%, and 29.9% vs. 28.9% at 3, 7, and 30 days, respectively p-value > .05). Hospital admission during the follow-up period was also similar for these two groups (1.8% vs. 2.8%, 3.9% vs. 5.7%, and 11.3% vs. 15.0% at 3, 7, and 30 days, respectively p-value > .05). CONCLUSIONS: Patients discharged from the ED after referral for medicine admission were not at significantly increased risk of subsequent ED revisit or hospital admission compared with nonreferred patients. This study illustrates the opportunity for collaboration between ED and medicine providers to refine disposition plans for patients who may fall into the "gray zone."

Identification of Emergency Care-Sensitive Conditions and Characteristics of Emergency Department Utilization.

Importance: Monitoring emergency care quality requires understanding which conditions benefit most from timely, quality emergency care. Objectives: To identify a set of emergency care-sensitive conditions (ECSCs) that are treated in most emergency departments (EDs), are associated with a spectrum of adult age groups, and represent common reasons for seeking emergency care and to provide benchmark national estimates of ECSC acute care utilization. Design, Setting, and Participants: A modified Delphi method was used to identify ECSCs. In a cross-sectional analysis, ECSC-associated visits by adults (aged ≥18 years) were identified based on International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes and analyzed with nationally representative data from the 2016 US Nationwide Emergency Department Sample. Data analysis was conducted from January 2018 to December 2018. Main Outcomes and Measures: Identification of ECSCs and ECSC-associated ED utilization patterns, length of stay, and charges. Results: An expert panel rated 51 condition groups as emergency care sensitive. Emergency care-sensitive conditions represented 16 033 359 of 114 323 044 ED visits (14.0%) in 2016. On average, 8 535 261 of 17 886 220 ED admissions (47.7%) were attributed to ECSCs. The most common ECSC ED visits were for sepsis (1 716 004 [10.7%]), chronic obstructive pulmonary disease (1 273 319 [7.9%]), pneumonia (1 263 971 [7.9%]), asthma (970 829 [6.1%]), and heart failure (911 602 [5.7%]) but varied by age group. Median (interquartile range) length of stay for ECSC ED admissions was longer than non-ECSC ED admissions (3.2 [1.7-5.8] days vs 2.7 [1.4-4.9] days; P < .001). In 2016, median (interquartile range) ED charges per visit for ECSCs were $2736 ($1684-$4605) compared with $2179 ($1118-$4359) per visit for non-ECSC ED visits (P < .001). Conclusions and Relevance: This comprehensive list of ECSCs can be used to guide indicator development for pre-ED, intra-ED, and post-ED care and overall assessment of the adult, non-mental health, acute care system. Health care utilization and costs among patients with ECSCs are substantial and warrant future study of validation, variations in care, and outcomes associated with ECSCs.

Lean Enterprise Transformation in VA: a national evaluation framework and study protocol.

BACKGROUND: The goal of Lean Enterprise Transformation (LET) is to go beyond simply using Lean tools and instead embed Lean principles and practices in the system so that it becomes a fundamental, collective mindset of the entire enterprise. The Veterans Engineering Resource Center (VERC) launched the Veterans Affairs (VA) LET pilot program to improve quality, safety, and the Veteran's experience. A national evaluation will examine the pilot program sites' implementation processes, outcomes and impacts, and abilities to improve LET adoption and sustainment. This paper describes the evaluation design for the VA LET national evaluation and describes development of a conceptual framework to evaluate LET specifically in healthcare settings. METHODS: A targeted literature review of Lean evaluation frameworks was performed to inform the development of the conceptual framework. Key domains were identified by a multidisciplinary expert group and then validated with key stakeholders. The national evaluation design will examine LET implementation using qualitative, survey, and quantitative methods at ten VA facilities. Qualitative data include site visits, interviews, and field observation notes. Survey data include an employee engagement survey to be administered to front-line staff at all pilot sites. Quantitative data include site-level quality improvement metrics collected by the Veterans Services Support Center. Qualitative, quantitative, and mixed-methods analyses will be conducted to examine implementation of LET strategic initiatives and variations in implementation success across sites. DISCUSSION: This national evaluation of a large-scale LET implementation effort will provide insights helpful to other systems interested in embarking on a Lean journey. Additionally, we created a multi-faceted conceptual framework to capture the specific features of a Lean healthcare organization. This framework will guide this evaluation and may be useful as an assessment tool for other organizations interested in implementing Lean principles at an enterprise level.