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Policy and financial pressures have driven up use of observation stays for patients in traditional Medicare and the Veterans' Affairs Healthcare System. Using claims data (2004-2014) from OptumLabs™ Data Warehouse, we examined whether people in private Medicare Advantage (MA) and commercial plans experienced similar changes. We found that use of observation increased rapidly for patients in MA plans-even though MA plans were not subject to the same pressures as government-run programs. In contrast, use of observation remained constant for people in commercial plans-except for enrollees 65 and older, for whom it increased somewhat. Privately insured patients returning to the hospital after an inpatient stay were increasingly likely to be placed under observation. Our results suggest that observation is rapidly replacing inpatient admissions and readmissions for many older patients in MA and commercial plans, while younger patients continue to be admitted as inpatients at relatively constant rates. [ABSTRACT FROM AUTHOR]

Background: Shared decision making in the emergency department (ED) can increase patient engagement for patients presenting with chest pain. However, little is known regarding which factors are associated with actual patient involvement in decision making or patients' desired involvement in emergency care decisions. We examined which factors were associated with patients' actual and desired involvement in decision making among ED chest pain patients. Methods: This is a secondary analysis of data from a randomized trial of a shared decision‐making intervention in ED patients with low‐risk chest pain. We evaluated the degree to which patients were involved in decision making using the OPTION‐12 (observing patient involvement) scale and patients' reported desire for involvement in decision making using the Control Preferences Scale (CPS). We measured the associations of patient factors with OPTION‐12 and CPS scores using multivariable regression. Results: Of the 898 patients enrolled, mean (±SD) age was 51.5 (±11.4) years and 59% were female. Multivariable analysis revealed that only two factors were significantly associated with OPTION‐12 scores: study site and use of the decision aid. OPTION‐12 scores were 10.3 (standard error = 0.6) points higher for patients randomized to the decision aid compared to usual care (p < 0.001). Higher health literacy was associated with lower scores on the CPS, indicating greater desire for involvement (odds ratio = 0.91, p < 0.001). Conclusions: Patients' reported desire for involvement in decision making was higher among those with higher health literacy. After study site and other potential confounding factors were adjusted for, only use of the decision aid was associated with observed patient involvement in decision making. As the science and practice of shared decision making in the ED moves toward implementation, high‐fidelity integration of the decision aid into the flow of care will be necessary to realize desired outcomes. [ABSTRACT FROM AUTHOR]

Objectives: Neurovascular and neurocritical care emergencies constitute a leading cause of morbidity/mortality. There has been great evolution in this field, including but not limited to extended time-window therapeutic interventions for acute ischemic stroke. The intent of this article is to evaluate the goals and future direction of clinical rotations in neurovascular and neurocritical care for emergency medicine (EM) residents., Methods: A panel of 13 board-certified emergency physicians from the Society for Academic Emergency Medicine (SAEM) neurologic emergencies interest group (IG) convened in response to a call for publications-three with fellowship training/board certification in stroke and/or neurocritical care; five with advanced research degrees; three who have been authors on national practice guidelines; and six who have held clinical duties within neurology, neurosurgery, or neurocritical care. A mixed-methods analysis was performed including a review of the literature, a survey of Council of Emergency Medicine Residency Directors (CORD) residency leaders/faculty and SAEM neuro-IG members, and a consensus review by this panel of select neurology rotations provided by IG faculty., Results: Thirteen articles for residency neurovascular education were identified: three studies on curriculum, three studies evaluating knowledge, and seven studies evaluating knowledge after an educational intervention. Intervention outcomes included the ability to recognize and manage acute strokes, manage intracerebral hemorrhage, calculate National Institutes of Health Stroke Scale (NIHSS), and interpret images. In the survey sent to CORD residency leaders and neuro-IG faculty, response was obtained from 48 programs. A total of 52.1% indicated having a required rotation (6.2% general neurology, 2% stroke service, 18.8% neurologic intensive care unit, 2% neurosurgery, 22.9% on a combination of services). The majority of programs with required rotations have a combination rotation (residents rotate through multiple services) and evaluations were positive., Conclusions: Variability exists in the availability of neurovascular/neurocritical care rotations for EM trainees. Dedicated clinical time in neurologic education was beneficial to participants. Given recent advancements in the field, augmentation of EM residency training in this area merits strong consideration.