Comparing Emergency Department Resident and Patient Perspectives on Costs in Emergency Care

Objectives: Costs of care are increasingly important in healthcare policy and, more recently, clinical care in the Emergency Department (ED). We compare ED resident and patient perceptions surrounding the costs of emergency care, compliance, communication, and education. Methods: We conducted a mixed methods study using surveys and qualitative interviews in a single, urban academic ED. The first study population was a convenience sample of adult patients (\u3e17 years of age), and the second was ED residents training at the same institution. Participants answered open- and closed-ended questions on costs, cost-related compliance, and communication. Residents answered additional questions on residency education on costs of care. Closed-ended data were tabulated and described using standard statistics while open-ended responses were analyzed using grounded theory. Results: Thirty ED patients and 24 ED residents participated in the study. Both ED patients and residents felt neutral regarding the importance of cost discussions and generally did not have knowledge of medical costs. Patients were comfortable discussing costs while residents were less comfortable. Additionally, some patients had cost concerns restricting compliance with treatment. Limitations to discussing costs included lack of time and perceived irrelevance. Generally, ED residents took costs into consideration during clinical decision-making, most commonly because of a feeling of personal responsibility to control healthcare costs. Nearly all ED residents agreed they had too little education regarding costs, and the most common suggestion for enhancing education was inclusion of price lists. Conclusions: There were several notable differences in patient and resident perspectives on cost discussions in the ED in this sample. While patients do not see cost discussions to be important, they are generally comfortable discussing costs yet do not report having sufficient knowledge on what care costs. ED residents think costs are important, but are less comfortable discussing them, primarily because they lack education on medical costs

Do emergency department patients receive a pathological diagnosis? A nationally-representative sample.

Introduction Understanding the cause of patients’ symptoms often requires identifying a pathological diagnosis. A single-center study found that many patients discharged from the emergency department (ED) do not receive a pathological diagnosis. We analyzed 17 years of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to identify the proportion of patients who received a pathological diagnosis at ED discharge. We hypothesized that many patients do not receive a pathological diagnosis, and that the proportion of pathological diagnoses increased between 1993 and 2009. Methods Using the NHAMCS data from 1993–2009, we analyzed visits of patients age ≥18 years, discharged from the ED, who had presented with the three most common chief complaints: chest pain, abdominal pain, and headache. Discharge diagnoses were coded as symptomatic versus pathological based on a pre-defined coding system. We compared weighted annual proportions of pathological discharge diagnoses with 95% CIs and used logistic regression to test for trend. Results Among 299,919 sampled visits, 44,742 met inclusion criteria, allowing us to estimate that there were 164 million adult ED visits presenting with the three chief complaints and then discharged home. Among these visits, the proportions with pathological discharge diagnosis were 55%, 71%, and 70% for chest pain, abdominal pain, and headache, respectively. The total proportion of those with a pathological discharge diagnosis decreased between 1993 and 2009, from 72% (95% CI, 69–75%) to 63% (95% CI, 59–66%). In the multivariable logistic regression model, those more likely to receive pathological diagnoses were females, African-American as compared to Caucasian, and self-pay patients. Those more likely to receive a symptomatic diagnosis were patients aged 30–79 years, with visits to EDs in the South or West regions, and seen by a physician in the ED. Conclusion In this analysis of a nationally-representative database of ED visits, many patients were discharged from the ED without a pathological diagnosis that explained the likely cause of their symptoms. Despite advances in diagnostic testing, the proportion of pathological discharge diagnoses decreased. Future studies should investigate reasons for not providing a pathological diagnosis and how this may affect clinical outcomes

National inventory of emergency departments in Singapore

Background: Emergency departments (EDs) are the basic units of emergency care. We performed a national inventory of all Singapore EDs and describe their characteristics and capabilities. Methods: Singapore EDs accessible to the general public 24/7 were surveyed using the National ED Inventories instrument ( http://www.emnet-nedi.org). ED staff members were asked about ED characteristics with reference to calendar year 2007. Results: Fourteen EDs participated (100% response). All EDs were located in hospitals, and most (92%) were independent departments. One was a psychiatric ED; the rest were general EDs. Among general EDs, all had a contiguous layout, with medical and surgical care provided in one area. All but two EDs saw both adults and children; one ED was adult-only, and the other saw only children. Six were in the public sector and seven in private health-care institutions, with public EDs seeing the majority (78%) of ED patients. Each private ED had an annual patient census of 60,000. They received 98% of ambulances and had an inpatient admission rate of 30%. Two public EDs reported being overcapacity; no private EDs did. For both public and private EDs, availability of consultant resources in EDs was high, while technological resources varied. Conclusion: Characteristics and capabilities of Singapore EDs varied and were largely dependent on whether they are in public or private hospitals. This initial inventory establishes a benchmark to further monitor the development of emergency care in Singapore

Educating Health Professionals about Drug and Device Promotion: Advocates' Recommendations

Mansfield and colleagues outline the recommendations from four advocacy groups for improving the education of health professionals on promotion of drugs and devices

Existing infrastructure for the delivery of emergency care in post-conflict Rwanda: An initial descriptive study

Background: Rwanda is a landlocked East-African country that was the site of the 1994 genocide, during which much of its health infrastructure was destroyed. It remains one of the poorest and least developed countries in the world. In the last two decades, there have been significant efforts to rebuild its healthcare system. No study has since examined Rwanda’s emergency medicine (EM) infrastructure. Study objective: To perform an initial descriptive study of EM infrastructure in post-conflict Rwanda. Methods: We employed two methods. The first was 160 h of direct observation at six healthcare sites in the capital city of Kigali leading to a descriptive understanding of Rwanda’s EM infrastructure. The second method utilized face-to-face narrative interviews based on a 5-item open-ended questionnaire with a convenience sample of 54 healthcare workers. Results: A relatively basic EM infrastructure was found to exist. Emergency care is available to all, though timely access and demand for payment are barriers to care. Emergency care is delivered at all levels, from local community health centres to district hospitals to national referral centres. The majority of physicians working in the Emergency Departments (EDs) are general practitioners, and only one hospital provides specialised training at the BLS level to EM practitioners. Prehospital care is almost entirely missing. The three most commonly cited problems facing EM infrastructure in Rwanda were lack of resources (94% of respondents), need for specialised EM training (89%), and absence of prehospital care (74%). All except one worker surveyed (98%) were satisfied with the progress Rwanda has made to improve EM in the last 10 years. Conclusion: Despite ongoing challenges, the infrastructure for the delivery of emergency care is much improved since 1994, and Rwanda’s continuing progress can serve as a model for EM development in other developing and/or post-conflict countries in Africa