Are Emergency Department Patient Sicker?
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National Trend in Vital Sign Abnormalities - Presented at the Fourth Annual Barsan Emergency Medicine Research Forum
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Are Emergency Department Patient Sicker?
- 1. Are Emergency Department Patients Sicker?: National Trend in Vital Sign Abnormalities Rama A. Salhi, MD MHS; Margaret Greenwood-Eriksen, MD MPH; Keith Kocher, MD MPH
- 2. Disclosures • None Department of Emergency Medicine
- 3. Background Department of Emergency Medicine
- 4. Background • Recent reports suggest that the intensity of ED billing practices are on the rise Department of Emergency Medicine
- 5. Background • It is unclear if this represents •Up-coding to maximize payments •Delayed implementation of EHRs/familiarity with appropriate billing practices •Increasing acuity/complexity of care rendered •Our goal in this analysis is to better quantify trends in acuity
- 6. Methods • Data - CDC National Hospital Ambulatory Medical Care Survey (NHAMCS) • Timespan - 2001-2016 • Excluded age <18 • Identified and analyzed measures of clinical acuity Department of Emergency Medicine
- 7. Methods
- 8. Methods • Weighted descriptive statistics (median, interquartile ranges [IQR]) were calculated and trended for: • Heart rate • Oxygen saturation • Temperature • Systolic blood pressure (SBP) • We also assessed for trends in hypotension (SBP <90) and tachycardia (heart rate >100). • Higher risk sub-populations of interest were also stratified, including age (<65 vs ≥65), payer (uninsured, private, government), and high-risk diagnoses.
- 9. Results • 507,367 visits were analyzed, representing 2,004,231,571 ED visits after appropriate weighting • Median age 43 •43% Male Department of Emergency Medicine
- 10. Results Department of Emergency Medicine
- 11. Interpretations and Conclusions • ED vital signs have remained largely unchanged over a span of 15 years • This stays true even within higher acuity subpopulations • These numbers suggest that greater intensity in ED billing practices is not explained by changes in vital signs. Department of Emergency Medicine
- 12. Limitations and Future Directions • While more resilient to confounding factors, is not immune to bias •This is only one definition of what it means to be “sick” •Looking at comorbid conditions may provide additional nuance • May still need to consider uptake of EHRs as a confounding factor
- 13. Thank You! • Dr. Keith Kocher • Dr. Margaret Greenwood-Eriksen Department of Emergency Medicine Questions?
- 14. References • Burke, Laura G., et al. "Are trends in billing for high-intensity emergency care explained by changes in services provided in the emergency department? An observational study among US Medicare beneficiaries." BMJ open 8.1 (2018): e019357. • Herring, Andrew A., et al. "High-intensity emergency department visits increased in California, 2002–09." Health Affairs 32.10 (2013): 1811-1819. • Venkatesh, Arjun K., et al. "Identification of emergency department visits in medicare administrative claims: Approaches and implications." Academic Emergency Medicine 24.4 (2017): 422-431. • Pitts, Stephen R., et al. "National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity." Annals of emergency medicine 60.6 (2012): 679-686. Department of Emergency Medicine
Editor's Notes
- My research project come to fruition the way most good resident research projects do: in a postnight shift delirium. Dr. Kocher and I sat in his office talking about different applications of big datasets to answer clinical questions when we began talking about patient acuity and the belief that our patients are getting sicker. Now, we all know that in practice we do our best to make sure our sickest patients get seen first, whether by the ESI triage numbers or by abnormality in vital signs – but is it true that there are more people vying for the front of the line, so to speak?
- There has been a lot of recent attention on increases in ED billing practices. There have been many interpretations of this data, and currently it is still unclear if it represents: Upcoding Temporal trends in EHR uptake Increasing acuity of the patients we treat The truth is that there are likely many factors contributing to the trends we’re seeing. Our goal here is to isolate the presenting acuity of our patients as a contributing factor.
- Our question really necessitates the use of longitudinal data to analyze temporal trends, leading us to use the NHAMCS data set. For those who may not be familiar with this data, it is a large survey which is collected and weighted in such a way to be nationally representative of ED visits. We included 15 years of available vital sign data among adults. The critical question in designing our methods is what does it mean to be “sick”. Certainly there were options to use ESI scores, comorbid conditions, use of advanced imaging or interventions, each of these carries their own limitations. Ultimately this lead us to the use of vital sign trends to avoid some of these limitations.
- Here we see a quick representation of our results. Over the 15 years we see minimal variation in the median values of each of these vital sign measures. We were fairly surprised to see this trend, so we cut it in a few different ways. This represents all adults. We also cut it to include our geriatric population, payer (uninsured, private, government), and high risk populations (people who carry diagnoses previously identified as carrying an increased mortality risk)
- As we saw on the previous slide, vital sign trends appear to be pretty stable over a period of 15 years. This is true even in populations that we might expect to have increasing acuity over that time frame. So, this leads us to believe that the trends we’re seeing in increased billing practices is not explained by increasing presenting acuity.
- Now, this is limited by a few things that we intend to look at in our next steps: First, as mentioned before, there is a question of whether or not these trends can be explained by increased uptake in the EHR. We would expect that as hospitals integrate EHRs that improve documentation and billing, we would see an increased trend in higher acuity visits Second, we should recognize that this gets only at one definition of what it means to be “sick”. We all know from clinical practice that this is a complicated, often subtle distinction, that is only partly explained by presenting vital signs. Parsing apart comorbid conditions (to the extent that we can in a secondary data analysis) may help us get at this subtlety.
- Thank you all for coming today and for your attention. And a special thanks to Drs. Kocher and Greenwood-Eriksen for their expertise and guidance with this project. I’m very happy to take any questions that people may have.