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BackgroundInsurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government-sponsored insurance had worse quality of care or in-hospital outcomes in acute ischemic stroke.Methods and resultsMultivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in-hospital mortality and postdischarge destination. We included 589 320 ischemic stroke patients treated at 1604 US hospitals participating in the Get With The Guidelines-Stroke program between 2012 and 2015. Uninsured patients with hypertension, high cholesterol, or diabetes mellitus were less likely to be taking appropriate control medications prior to stroke, to use an ambulance to arrive to the ED, or to arrive early after symptom onset. Even after adjustment, the uninsured were more likely than the privately insured to die in the hospital (

Objectives: The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm. Methods: We conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED. Results: Six e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/ safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings. Conclusions: We identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance. [ABSTRACT FROM AUTHOR]

To determine whether emergency department patients want to share their medical records across health systems through Health Information Exchange and if so, whether they prefer to sign consent or share their records automatically, 982 adult patients presenting to an emergency department participated in a questionnaire-based interview. The majority (N = 906; 92.3%) were willing to share their data in a Health Information Exchange. Half (N = 490; 49.9%) reported routinely getting healthcare outside the system and 78.6 percent reported having records in other systems. Of those who were willing to share their data in a Health Information Exchange, 54.3 percent wanted to sign consent but 90 percent of those would waive consent in the case of an emergency. Privacy and security were primary concerns of patients not willing to participate in Health Information Exchange and preferring to sign consent. Improved privacy and security protections could increase participation, and findings support consideration of “break-the-glass” provider access to Health Information Exchange records in an emergent situation. [ABSTRACT FROM AUTHOR]

Background: Insurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government‐sponsored insurance had worse quality of care or in‐hospital outcomes in acute ischemic stroke. Methods and Results: Multivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in‐hospital mortality and postdischarge destination. We included 589 320 ischemic stroke patients treated at 1604 US hospitals participating in the Get With The Guidelines‐Stroke program between 2012 and 2015. Uninsured patients with hypertension, high cholesterol, or diabetes mellitus were less likely to be taking appropriate control medications prior to stroke, to use an ambulance to arrive to the ED, or to arrive early after symptom onset. Even after adjustment, the uninsured were more likely than the privately insured to die in the hospital (<65 years, OR 1.33 [95% CI 1.22‐1.45]; ≥65 years OR 1.54 [95% CI 1.34‐1.75]), and among survivors, were less likely to go to inpatient rehab (<65 OR 0.63 [95% CI 0.6‐0.67]; ≥65 OR 0.56 [95% CI 0.5‐0.63]). In contrast, patients with Medicare and Medicaid were more likely to be discharged to a Skilled Nursing Facility (<65 years OR 2.08 [CI 1.96‐2.2]; OR 2.01 [95% CI 1.91‐2.13]; ≥65 years OR 1.1 [95% CI 1.07‐1.13]; OR 1.41 [95% CI 1.35‐1.46]). Conclusions: Preventative care prior to ischemic stroke, time to presentation for acute treatment, access to rehabilitation, and in‐hospital mortality differ by patient insurance status.

Introduction: Medical clearance is required to label patients with mental illness as free of acute medical concerns. However, tests may extend emergency department lengths of stay and increase costs to patients and hospitals. The objective of this study was to determine how knowledgeable emergency and psychiatric providers are about the costs of tests used for medical clearance., Materials and Methods: We surveyed the department of psychiatry (Psych) and department of emergency medicine (EM) faculty and residents to obtain their estimates of the costs of 18 laboratory/imaging studies commonly used for medical clearance. Survey responses were analyzed using the Wilcoxon signed-rank test to compare the median cost estimates between residents and faculty in EM and Psych., Results: A total of 99 physicians (response rate, 47.8%) completed the survey, including 47 faculty (EM = 28; Psych = 20) and 52 residents (EM = 29; Psych = 23). Across all the groups, cost estimates for tests were inaccurate, off by several hundred dollars for three tests, and by $13-$80 for 15. Significant differences between EM and Psych providers for estimated median costs of specific tests included between residents for urine drug screens (EM: $800; Psych: $50; P < 0.0001) and ECG (EM: $25; Psych: $75; P = 0.004); between faculty for urinalysis (EM: $40; Psych: $18; P = 0.020) and urine drug screen (EM: $100; Psych: $10; P < 0.0001); and between all physicians for urine drug screen (EM: $500; Psych: $50; P < 0.0001)., Conclusion: Further education on the financial costs of medical clearance is needed to inform workup decisions and consensus between emergency and psychiatric providers., Competing Interests: There are no conflicts of interest.