Age-Related Disparities in Trauma Center Access for Severe Head Injuries Following the Release of the Updated Field Triage Guidelines

Objective: In 2006, the American College of Surgeons’ Committee on Trauma and the Center for Disease Control released field triage guidelines with special consideration for older adults. Additional considerations for direct transport to a Level I or II trauma center (TC) were added in 2011, reflecting perceived undertriage to TCs for older adults. We examined whether age-based disparities in TC care for severe head injury decreased following introduction of the 2011 revisions. Methods: A pre-post design analyzing the 2009 and 2012 Healthcare Cost and Utilization Project State Emergency Department Databases (SEDD) and State Inpatient Databases (SID) with multivariable logistic regressions considered changes in (1) the trauma designation of the emergency department where treatment was initiated and (2) transfer to a TC following initial treatment at a non-TC. Results: Compared with adults aged 18–44 years, after multivariable adjustment, in both years TC care was less likely for adults aged 45–64 years (OR: 0.76 in 2009 and 0.74 in 2012), aged 65–84 years (OR: 0.61 and 0.59), and aged 85+ years (OR: 0.53 and 0.56). Between 2009 and 2012, the likelihood of TC care increased for all age groups, with the largest increase among those aged 85+ years (OR = 1.18), which was statistically different (p = .02) from the increase among adults aged 18–44 years (OR = 1.12). The analysis of transfers yielded similar results. Conclusions: Although patterns of increased TC treatment for all groups with severe head trauma indicate improvements, age-based disparities persisted

Modeled Health and Economic Impact of Team-Based Care for Hypertension

IntroductionTeam-based interventions for hypertension care have been widely studied and shown effective in improving hypertension outcomes. Few studies have evaluated long-term effects of these interventions; none have assessed broad-scale implementation. This study estimates the prospective health, economic, and budgetary impact of universal adoption of a team-based care intervention model that targets people with treated but uncontrolled hypertension in the U.S.MethodsAnalysis was conducted in 2014−2015 using a microsimulation model, constructed with various data sources from 1948 to 2014, designed to evaluate prospective cardiovascular disease (CVD)−related interventions in the U.S. population. Ten-year primary outcomes included prevalence of uncontrolled hypertension; incident myocardial infarction, stroke, CVD events, and CVD-related mortality; intervention and net medical costs by payer; productivity; and quality-adjusted life years.ResultsAbout 4.7 million (13%) fewer people with uncontrolled hypertension and 638,000 prevented cardiovascular events would be expected over 10 years. Assuming $525 per enrollee, implementation would cost payers$22.9 billion, but $25.3 billion would be saved in averted medical costs. Estimated net cost savings for Medicare approached$5.8 billion. Net costs were especially sensitive to intervention costs, with break-even thresholds of $300 (private),$450 (Medicaid), and $750 (Medicare).ConclusionsNationwide adoption of team-based care for uncontrolled hypertension could have sizable effects in reducing CVD burden. Based on the study’s assumptions, the policy would be cost saving from the perspective of Medicare and may prove to be cost effective from other payers’ perspectives. Expected net cost savings for Medicare would more than offset expected net costs for all other insurers

Age-Related Disparities in Trauma Center Access for Severe Head Injuries Following the Release of the Updated Field Triage Guidelines

Objective: In 2006, the American College of Surgeons’ Committee on Trauma and the Center for Disease Control released field triage guidelines with special consideration for older adults. Additional considerations for direct transport to a Level I or II trauma center (TC) were added in 2011, reflecting perceived undertriage to TCs for older adults. We examined whether age-based disparities in TC care for severe head injury decreased following introduction of the 2011 revisions. Methods: A pre-post design analyzing the 2009 and 2012 Healthcare Cost and Utilization Project State Emergency Department Databases (SEDD) and State Inpatient Databases (SID) with multivariable logistic regressions considered changes in (1) the trauma designation of the emergency department where treatment was initiated and (2) transfer to a TC following initial treatment at a non-TC. Results: Compared with adults aged 18–44 years, after multivariable adjustment, in both years TC care was less likely for adults aged 45–64 years (OR: 0.76 in 2009 and 0.74 in 2012), aged 65–84 years (OR: 0.61 and 0.59), and aged 85+ years (OR: 0.53 and 0.56). Between 2009 and 2012, the likelihood of TC care increased for all age groups, with the largest increase among those aged 85+ years (OR = 1.18), which was statistically different (p = .02) from the increase among adults aged 18–44 years (OR = 1.12). The analysis of transfers yielded similar results. Conclusions: Although patterns of increased TC treatment for all groups with severe head trauma indicate improvements, age-based disparities persisted

Teaching and Clinical Efficiency: Competing Demands

Introduction: Teaching ability and efficiency of clinical operations are important aspects of physician performance. In order to promote excellence in education and clinical efficiency, it would be important to determine physician qualities that contribute to both. We sought to evaluate the relationship between teaching performance and patient throughput times.Methods: The setting is an urban, academic emergency department with an annual census of 65,000patient visits. Previous analysis of an 18-question emergency medicine faculty survey at this institution identified 5 prevailing domains of faculty instructional performance. The 5 statistically significant domains identified were: Competency and Professionalism, Commitment to Knowledge and Instruction, Inclusion and Interaction, Patient Focus, and Openness and Enthusiasm. We fit a multivariate, random effects model using each of the 5 instructional domains for emergency medicine faculty as independent predictors and throughput time (in minutes) as the continuous outcome. Faculty that were absent for any portion of the research period were excluded as were patient encounters without direct resident involvement.Results: Two of the 5 instructional domains were found to significantly correlate with a change inpatient treatment times within both datasets. The greater a physician’s Commitment to Knowledge and Instruction, the longer their throughput time, with each interval increase on the domain scale associated with a 7.38-minute increase in throughput time (90% confidence interval [CI]: 1.89 to 12.88 minutes). Conversely, increased Openness and Enthusiasm was associated with a 4.45-minute decrease in throughput (90% CI: 8.83 to 0.07 minutes).Conclusion: Some aspects of teaching aptitude are associated with increased throughput times (Openness and Enthusiasm), while others are associated with decreased throughput times (Commitment to Knowledge and Instruction). Our findings suggest that a tradeoff may exist between operational and instructional performance. [West J Emerg Med. 2012;13(2):186–193.] 

Teaching and Clinical Efficiency: Competing Demands

Introduction: Teaching ability and efficiency of clinical operations are important aspects of physicianperformance. In order to promote excellence in education and clinical efficiency, it would be importantto determine physician qualities that contribute to both. We sought to evaluate the relationship betweenteaching performance and patient throughput times.Methods: The setting is an urban, academic emergency department with an annual census of 65,000patient visits. Previous analysis of an 18-question emergency medicine faculty survey at this institutionidentified 5 prevailing domains of faculty instructional performance. The 5 statistically significantdomains identified were: Competency and Professionalism, Commitment to Knowledge andInstruction, Inclusion and Interaction, Patient Focus, and Openness and Enthusiasm. We fit amultivariate, random effects model using each of the 5 instructional domains for emergency medicinefaculty as independent predictors and throughput time (in minutes) as the continuous outcome. Facultythat were absent for any portion of the research period were excluded as were patient encounterswithout direct resident involvement.Results: Two of the 5 instructional domains were found to significantly correlate with a change inpatient treatment times within both datasets. The greater a physician’s Commitment to Knowledge andInstruction, the longer their throughput time, with each interval increase on the domain scale associatedwith a 7.38-minute increase in throughput time (90% confidence interval [CI]: 1.89 to 12.88 minutes).Conversely, increased Openness and Enthusiasm was associated with a 4.45-minute decrease inthroughput (90% CI: 8.83 to 0.07 minutes).Conclusion: Some aspects of teaching aptitude are associated with increased throughput times(Openness and Enthusiasm), while others are associated with decreased throughput times(Commitment to Knowledge and Instruction). Our findings suggest that a tradeoff may exist betweenoperational and instructional performance