Health resource utilization of the emergency department headache "repeater"

OBJECTIVE: To document the health resource utilization of patients who repeatedly use emergency department services for headache care. BACKGROUND: Patients with headache who frequently use emergency department services may differ from patients with more typical, episodic migraine. Previous studies of health resource utilization have often failed to distinguish the high utilizer as a specific subset of the migraine population. DESIGN: Retrospective review of urgent care/emergency department charts, clinic charts, and pharmacy rosters. PATIENTS AND METHODS: Patients who made three or more visits for headache to an urgent care/emergency department (UC/ED) facility for headache over a 6-month study period were identified and designated as "repeaters" for this study. Pharmacy profiles and appointment histories of 52 of the 54 repeaters whose records were available were reviewed for the 12 months prior to the study period. RESULTS: Over the 6-month study period, 518 patients visited the UC/ED 1004 times for primary headache complaints. Fifty-four (10%) repeaters made 502 visits (50% of total visits; mean 9.3, range 3-50). In the 12 months prior to the study period, 52 of these repeaters made 1832 visits to the UC/ED or clinic (mean 35.2, range 0-178): 1458 (79.6%) were headache related, and 1271 (69.4%) of all visits were to the UC/ED. An estimated 12-month cost for all visits was $183,760. Pharmacy rosters showed use of narcotics in 41 of the 52 patients (annual mean +/- SD, 613 +/- 670 tablets), benzodiazepines in 30 patients (500 +/- 486 tablets), and butalbital products in 27 patients (395 +/- 590 tablets). Mean daily use of all symptomatic medications combined was 3.9 +/- 3.2 doses/day. CONCLUSION: Health resource utilization of emergency department headache repeaters is predominantly headache-related acute care. Associated medication overuse is frequently present. Efforts to improve care for patients with headache will benefit from distinguishing the high utilizer as a subset of the migraine population.     

Impact of a group-based model of disease management for headache

OBJECTIVES: To assess the impact of a group-based model of disease management for patients with headache. BACKGROUND: Despite advances in the acute and preventive treatment of migraine, many patients with headache remain misdiagnosed and undertreated. Models of care that incorporate principles of disease management may improve headache care. DESIGN AND METHODS: This was a prospective, open-label, observational study. Patients with headache were referred by physicians or identified from emergency department records. Patients attended a group session led by a registered nurse practitioner, and later had follow-up consultation. Charts and computer records were reviewed to document triptan costs and headache-related visits for 6 months before and after the intervention. Changes in headache frequency and severity were assessed. RESULTS: Triptan costs for 264 patients and chart review for 250 were available. Six-month triptan costs increased $5423 US dollars(19%), headache-related visits were reduced by 32%, and headache-related emergency department visits were reduced by 49%. Severe headache frequency was reduced in 62 (86%) of 72 patients who initially had severe headaches more than 2 days per week. Patients identified by emergency department screening accounted for 21% of the study group, 31% of the baseline triptan costs, and 46% of the baseline visits. For the entire study group, reduced visits yielded a net savings of $18,757 US dollars despite increased triptan costs. CONCLUSIONS: Implementation of this group-based model produced a reduction in emergency department and clinic visits, significant clinical improvement, a small increase in pharmacy costs, and overall cost reduction. The greatest improvement in each outcome measure was seen in patients most severely afflicted at baseline. Our results suggest that the principles of disease management may be applied effectively to a headache population, with a positive financial impact on a managed care organization.     

Evaluation and Treatment of Headache Patients in the Emergency Department: A Survey.

SYNOPSIS
Patients with headache represent a common diagnostic and treatment challenge for health care providers in the emergency department. The therapeutic options continue to grow, yet many studies imply that narcotics continue to be a frequently chosen treatment. In this retrospective cross-sectional survey, the evaluation and treatment patterns of patients presenting to an academic medical center emergency department with a primary diagnosis of headache were analyzed. Headache disorders accounted for 1.7% of all visits to the emergency department. Migraine headache was the most common headache diagnosis representing 60% of headache visits followed by headache of no obvious source at 25%. Narcotics were the most common treatment employed (180 patient-visits) in all patients and non-steroidal anti-inflammatory agents were the second most common agent used (86 patient visits). Narcotics were also the most common therapy in migraine headache patients (152 patient-visits) while ergotamines were used in less than one-third of patient-visits (36 patient-visits). Therapy of headache patients in the emergency department continues to rely on narcotics. Methods of interrupting the dependence on narcotics need to be explored if newer non-narcotic therapies are to be successful.     

A survey of pain-related hospitalizations, emergency department visits, and physician office visits reported by cancer patients with and without history of breakthrough pain.

Pain is a common problem for cancer patients and can result in substantial medical costs, but little is known about the characteristics of pain that may predict these costs. This study applied telephone survey methodology to investigate the relationship between breakthrough pain (BTP) and the use of medical resources in a cancer population with pain. A nonrandom sample of 1,000 cancer patients was contacted by using standard telephone survey techniques. Eligible patients were questioned about the occurrence of BTP and pain-related hospitalizations, emergency department visits, and physician office visits. Patients who indicated that they had experienced BTP were compared with similar patients who had not experienced BTP by using cost estimations derived from patient reports of health care use. The analysis indicated that BTP patients were more likely to have experienced pain-related hospitalizations and physician office visits. When statistical control was made for patient ratings of the effectiveness of scheduled analgesics, BTP had higher costs associated with pain-related hospitalizations and physician office visits. The total cost of pain-related hospitalizations, emergency visits, and physician office visits was 12,000 US dollars/yr per BTP patient and 2,400 US dollars/yr per non-BTP patient. Cancer patients with BTP may sustain higher direct medical costs than patients without BTP. Implications and limitations of the study are discussed, and studies that will further clarify the relationship between BTP and medical costs are encouraged.     

Dispensing home nebulizers for acute wheezing from the hospital is cost-effective

The objective was to investigate the use characteristics of home nebulizers and to measure the benefit gained from dispensing home nebulizers (compared with their cost) to patients from the hospital. During the study period, August 28,1996 to May 17,1997, a sample of 232 of the 291 entries from a log of home nebulizers dispensed by the hospital respiratory care department were surveyed over the telephone. Of the 232 study subjects under the age of 21, a telephone interview of a guardian or supervising adult was completed in 106 subjects (46%) a mean of 43 weeks after the home nebulizer was prescribed (47% of the cohort received their home nebulizers from the inpatient service and another 47% were discharged with home nebulizers from the emergency department (ED)). An average of 3.6 estimated additional ED visits and 5.4 office/clinic visits for each patient were prevented by the home nebulizer. The benefit (savings from reduced ED and office visits alone) to cost ratio estimates range from $855:$90 to $1710:$90 or more. The overwhelming majority of the patients felt that the home nebulizer was a good idea, it was easy to use, they had no problems with the nebulizer and they received adequate training for home nebulizer use. Home nebulizers are a cost-effective means of providing home nebulized albuterol for selected outpatients. Hospital inpatient units and EDs which have the ability to dispense a home nebulizer, have an additional therapeutic option available for selected patients who may benefit from it. Medical insurance companies should fully support (ie, pay for) home nebulizers because it is cost effective. If there is any concern about the reliability of the patient to follow-up with their primary physician, the patient's primary physician should be contacted to discuss the feasibility of discharging the patient with a home nebulizer.     

Optimizing quality, service, and cost through innovation

With dramatic increases in health care costs and growing concerns about the quality of health care services, nurse executives are seeking ways to transform their organizations to improve operational and financial performance while enhancing quality care and patient safety. Nurse leaders are challenged to meet new cost, quality and service imperatives, and change cannot be achieved by traditional approaches, it must occur through innovation. Imagine an organization that can mitigate a $56 million loss in revenue and claim the following successes: Increase admissions by a 8 day and a $5.5 million annualized increase by repurposing existing space. Decrease emergency department holding hours by an average of 174 hours a day, with a labor savings of $502,000 annually. Reduce overall inpatient length of stay by 0.5 day with total compensation running $4.2 million less than the budget for first quarter of 2010. Grow emergency department volume 272 visits greater than budgeted for first quarter of 2010. Complete admission assessments and diagnostics in 90 minutes. This article will address how these outcomes were achieved by transforming care delivery, creating a patient transition center, enhancing outreach referrals, and revising admission processes through collaboration and innovation.     

Center of excellence for headache care: group model at Kaiser Permanente

OBJECTIVE: To evaluate the effectiveness of a disease management model for primary headache by: (1) assessing improvement in patients' quality of life, (2) decreasing headache-related visits to primary care and emergency departments, and (3) maintaining high levels of patient and physician satisfaction. BACKGROUND: Patients with headache regularly seek health care but, in general, are dissatisfied with the care they receive. Patients with primary headaches utilize resources and cost health plans more than patients with other chronic diseases. Primary care visits are time restricted, prohibiting adequate headache evaluation and management. Practice guidelines are inconsistently followed, and access to headache specialists is limited. This headache management program implemented an alternative means of delivering care to manage large volumes of patients with headache. A multidisciplinary team approach coordinated by a neurologist, utilizing education and a nurse practitioner as the main provider of care, was the central process of the program. METHODS: This was a pilot study involving a prospective cohort with defined outcome measures. Inclusion criteria were adult patients with primary headaches. Patients initially attended an educational session instructed by a neurologist and a nurse practitioner. The patient was subsequently evaluated by the nurse practitioner who developed and coordinated a comprehensive individual treatment plan. The Migraine-Specific Quality of Life and the Medical Outcomes Study 36-Item Short Form Questionnaires were completed at baseline, at follow-up visits, and 6 months after completion of the program. Subjective patient assessment of improvement in their headaches, chart review for tabulation of headache-related visits, and primary care physician satisfaction surveys were measured. RESULTS: Both the Migraine-Specific questionnaire and the Short Form-36 measurements demonstrated a statistically significant improvement at 8 weeks, and this was maintained for 6 months after completing the program. At completion of the program, 92% of patients reported subjective improvement. Patient visits for headaches to primary care and emergency departments showed a significant decrease. High levels of satisfaction for primary care physicians were achieved. CONCLUSIONS: A disease management model using a multidisciplinary team improved individualized patient care. This model increased patient/provider rapport and communication through an educational class. It empowered the patient to take control of their health care by utilizing shared decision making. Patient satisfaction improved and overall health care utilization was reduced.     

Impact of the ABCDE triage in primary care emergency department on the number of patient visits to different parts of the health care system in Espoo City

Background

Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland.

Methods

The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital). A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse). The introduction of this triage system was combined with information to the public on the "correct" use of emergency services.

Results

After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month) as compared to the three previous years in the EDs. The Number of visits to public sector GPs during office hours did not alter. Implementation of ABCDE-triage combined with public guidance was associated with decreased total number of doctor visits in public health care. During same period, the number of patient visits in the private health care increased. Simultaneously, the number of doctor visits in secondary health care ED did not alter.

Conclusions

The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the secondary health care EDs. Limiting the access of less urgent patients to ED may redirect the demands of patients to private sector rather than office hours GP services.     

Emergency treatment of headache

Headache is a frequent presenting complaint in the emergency department. Once a diagnosis is established, and significant organic disease can be ruled out, relief of pain must be addressed. Referral for follow-up care and narcotic habituation is a recurrent problem for the emergency physician. This article discusses the differential diagnosis of headache, evaluation of the emergency room patient, and treatment of the patient with headache.     

Cost analysis of the History,ECG, Age,Risk factors,and initial Troponin (HEART) Pathway randomized control trial

Introduction

The HEART Pathway is a diagnostic protocol designed to identify low-risk patients presenting to the emergency department with chest pain that are safe for early discharge. This protocol has been shown to significantly decrease health care resource utilization compared with usual care. However, the impact of the HEART Pathway on the cost of care has yet to be reported.

Narcotic bowel syndrome

Background

Narcotic bowel syndrome is characterized by chronic or recurrent abdominal pain associated with escalating doses of narcotic pain medications. It may occur in as many as 4% of all patients taking opiates, and yet few physicians are aware that the syndrome exists.

Objectives

The objectives of this case report are to raise awareness of narcotic bowel syndrome among emergency physicians, as well as review the clinical features, diagnosis, pathophysiology, and emergency department (ED) management of the syndrome.

Case Report

We report a case of narcotic bowel syndrome diagnosed in a 24-year-old woman after > 1 year of ED visits for recurrent abdominal pain of unknown origin.

Conclusions

It is particularly important for emergency physicians to be familiar with this syndrome, as many patients with narcotic bowel syndrome seek evaluation and treatment in the ED. Although the diagnosis is unlikely to be made in the ED, timely referral for evaluation of this syndrome may help patients to receive definitive treatment for their recurrent and chronic pain.     

The accuracy of pulse oximetry in emergency department patients with severe sepsis and septic shock: a retrospective cohort study

Background

Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care specialists are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to tertiary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for those patients who need it the most.

Methods

A face-to-face triage system based on the letters A (patient directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs was applied in the main ED in the City of Vantaa, Finland (Peijas Hospital) as an attempt to provide immediate treatment for the most acute patients. The first step was an initial patient assessment by a health care professional (triage nurse). If the patient was not considered to be in need of immediate care (i.e. A-D) he was allocated to group E and examined after the more urgent patients were treated. The introduction of this triage system was combined with information to the public on the "correct" use of emergency services. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the combined ED. To study the effect of the intervention on patient flow, numbers monthly visits to doctors were recorded before and after intervention in Peijas ED and, simultaneously, in control EDs (Myyrmäki in Vantaa, Jorvi and Puolarmetsä in Espoo). To study does the implementation of the triage system redirect patients to other health services, numbers of monthly visits to doctors were also scored in the private health care and public office hour services of Vantaa primary care.

Results

The number of patient visits to a primary care doctor in 2004 decreased by up to eight percent (340 visits/month) as compared to the previous year in the Peijas ED after implementation of the ABCDE-triage system. Simultaneously, doctor visits in tertiary health care ED increased by ten percent (125 visits/month). ABCDE-triage was not associated with a subsequent increase in the number of patient visits in the private health care or office hour services. The number of ED visits in the City of Espoo, used as a control where no triage was applied, remained unchanged.

Conclusions

The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the tertiary health care EDs.     

Abortive Headache Therapy With Intramuscular Dihydroergotamine

During a six month period, intramuscular dihydroergotamine mesylate (1 mg.) was given to 43 patients (75 headache episodes) who presented to the office after oral medications failed to abort their headaches. Headaches were successfully aborted in 71%, with most responses occurring between 30-minutes and 4-hours after injection. Side effects were common (61%) but not serious; sedation developed in 25%, nausea in 24%, transient worsening of headaches in 15%, body aches in 11%, diarrhea in 5%, and in 13%, headaches that were successfully aborted relapsed within 24 hours. Intramuscular dihydroergotamine, although under-used, is cost effective, practical, and well suited for busy medical offices. Its appropriate use can reduce the need for narcotic analgesics and emergency room visits.     

Making education count: the nurse's role in asthma education using a medical home model of care

Asthma care for patients who have limited health literacy is very costly. The resources to help patients who have lower health literacy levels are very few are not well identified. Significant gains in asthma control, self-efficacy in managing asthma, and improvement in overall costs of care for this patient population can be achieved when health literacy challenges are addressed. This research suggests that one-on-one education with an asthma educator that specifically addresses health literacy levels and care designed around the National Asthma Guidelines can produce significant reductions in the cost for asthma care through decreased emergency department visits and hospitalizations, and improved self-management of asthma exacerbations.     

Narcotic withdrawal in the emergency department

Patients in narcotic withdrawal can be very disruptive in an emergency department. An understanding of the dynamics of narcotic addiction and withdrawal is useful for the emergency physician. Narcotics are used for the euphoria they provide; however, chronic use results in physiological and psychological changes. Research into the endorphin system has provided a model of narcotic addiction and withdrawal. Effective therapies now exist for use in the emergency department.     

Emergency department care: Cost awareness by health care providers

With the escalation of health care costs during the past decade, it has become increasingly important for the physician to be aware of the cost of various components of health care delivery. The following study was undertaken to ascertain the “cost awareness” of four different groups of health care providers. This was accomplished by having these groups estimate the cost of patient visits to an emergency department. Significant errors were observed in these cost estimations, and error trends were seen to occur that were independent of education and experience.     

Practice and Economics Cost Considerations in Headache Treatment Part 2: Acute Migraine Treatment

Today's physician has many useful medication options available for acute migraine treatment. There is a wide cost range among these drugs and today's health care environment demands that cost be factored into the decision process. Effective migraine abortive treatment decreases the costs of repeat dosing and disability. Early use of migraine abortive medication can increase its rapidity of action and effectiveness. Adjunctive medication such as metoclopramide ($0.10) is inexpensive and may improve the effectiveness of the primary abortive medication.
Over-the-counter medications such as aspirin ($0.02/325 mg), Excadrin· ($0.09/tablet), ibuprofen ($0.04/200 mg), or naproxen sodium ($0.09/220 mg) are inexpensive and effective. "Triple therapy" combining metoclopramide, a nonsteroidal ant-inflammatory agent, and an ergotamine preparation may improve tolerance and effectiveness of the ergot. Locally compounded dihydroergotamine nasal spray is inexpensive ($0.78/1 mg spray). The cost of using oral sumatriptan can be almost halved by prescribing half of a 50-mg tablet.
Emergency department services are expensive. Huge cost savings occur through self-controlled administration of oral, rectal, or even intramuscular narcotic medications. Oral narcotic agents such as hydromorphone ($0.42/4 mg) and meperidine ($0.92/200 mg) are generally used in inadequate doses to be effective for severe migraine. Guidelines are given for more effective use of these agents.
Sophisticated comparative studies are needed to evaluate, not only the direct costs of medications, but all costs of treatment of an acute migraine attack, as well as Indirect costs to the patient, family, and society.     

Health Care Resource Utilization and Medical Costs of Spinal Cord Injury With Neuropathic Pain in a Commercially Insured Population in the United States

ObjectiveTo evaluate health care resource use, costs, and cost drivers among patients with neuropathic pain (NeP) after spinal cord injury (SCI) in a commercially insured population.DesignRetrospective longitudinal cohort study comparing SCI patients with and without NeP.SettingTruven Health MarketScan commercial claims database from 2005 through 2012.ParticipantsCommercially insured SCI patients with NeP (n=3524) propensity score matched to SCI patients without NeP (n=3524).InterventionsNot applicable.Main Outcomes MeasuresHealth care resource utilization and expenditures for the 12 months after NeP onset (index event; identified through International Classification of Diseases, 9th Revision, Clinical Modification diagnosis 338.0x or use of NeP-specific antiepileptic drugs or NeP-specific antidepressants) in patients with SCI compared with matched patients without NeP.ResultsUtilization over 12 months postindex among patients with SCI-associated NeP was higher than among SCI-only patients for inpatient admissions (27.4% vs 22.1%), emergency department visits (36.7% vs 26.4%), and office visits per patient (mean ± SD: 13.0±9.5 vs 9.5±8.3); all P values were <.001. All-cause expenditures showed adjusted incremental costs of $22,545 (95% confidence interval, $19,010–$26,168) per patient with SCI-associated NeP during the 12-month postindex period.ConclusionsPatients with evidence of NeP secondary to SCI have significantly higher health care utilization and total costs compared with SCI patients without evidence of NeP. Factors contributing to NeP in patients with SCI need to be clinically assessed to determine the optimal approach for treating these individuals.     

A Cost-Analysis of an Interdisciplinary Pediatric Chronic Pain Clinic

Chronic pain is characterized by high rates of functional impairment, health care utilization, and associated costs. Research supports the use of comprehensive, interdisciplinary treatment approaches. However, many hospitals hesitate to offer this full range of services, especially to Medi-Cal/Medicaid patients whose services are reimbursed at low rates. This cost analysis examines the effect on hospital and insurance costs of patients' enrollment in an interdisciplinary pediatric pain clinic, which includes medication management, psychotherapy, biofeedback, acupuncture, and massage. Retrospective hospital billing data (inpatient/emergency department/outpatient visits, and associated costs/reimbursement) from 191 consecutively enrolled Medi-Cal/Medicaid pediatric patients with chronic pain were used to compare 1-year costs before initiating pain clinic services with costs 1 year after. Pain clinic patients had significantly fewer emergency department visits, fewer inpatient stays, and lower associated billing, compared with the year before without interdisciplinary pain management services. Cost savings to the hospital of $36,228 per patient per year and to insurance of $11,482 per patient per year were found even after pain clinic service billing was included. Analyses of pre-pain clinic costs indicate that these cost reductions were likely because of clinic participation. Findings provide economic support for the use of interdisciplinary care to treat pediatric chronic pain on an outpatient basis from a hospital and insurance perspective.