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Importance: The Medicare Competitive Bidding Program (CBP), a policy that reduced durable medical equipment prices, was implemented starting in 2011. Legislation introduced in 2024 aims to remove supplemental oxygen from the CBP because of concerns that recent decreases in oxygen prescribing are due to lower prices set by the CBP, which may have decreased supply and, in turn, limited oxygen access for patients with chronic lung diseases. However, low-value prescribing of oxygen is also prevalent in practice, and decreased oxygen prescription rates may not have necessarily caused harm. Little is known about the association of the CBP with patient use, outcomes, or spending., Objective: To examine the association between the 2011 and 2013 implementation of the CBP and supplemental oxygen use, clinical outcomes, and supplemental oxygen spending among patients with chronic obstructive pulmonary disease (COPD)., Design, Setting, and Participants: This cohort study used a difference-in-differences (DID) method to evaluate the association between implementation of the CBP and the outcomes of interest. Patients aged 65 to 100 years with COPD living in CBP areas were compared with those living in areas where the CBP was not yet or never implemented. The study included 100% fee-for-service Medicare data of beneficiaries enrolled between July 1, 2009, and December 31, 2015. The data analysis was performed between June 6, 2023, and August 16, 2024., Exposure: The 2011 and 2013 implementation cycles of the Medicare CBP., Main Outcomes and Measures: The primary outcomes were new prescriptions of oxygen during a 6-month period among beneficiaries with COPD and discontinuation of oxygen during a 6-month period among beneficiaries with COPD previously prescribed oxygen. Secondary outcomes included switches between oxygen types (gas, liquid, or concentrator), all-cause mortality, all-cause unplanned hospitalizations, COPD hospitalizations, and mean monthly allowed charges (total spending) over a 6-month period. The analysis was performed using the Callaway-Sant'Anna method, a dynamic DID model for policies with staggered implementation., Results: Among 5 753 308 Medicare beneficiaries with COPD (mean [SD] age, 79.2 [8.4] years; 55.1% female), 25.9% received supplemental oxygen for at least one 6-month period during the study. The CBP was not associated with differential changes in new oxygen prescribing (DID estimate, -0.19 percentage points; 95% CI, -2.45 to 2.08 percentage points) or oxygen discontinuations (DID estimate, -0.77 percentage points; 95% CI, -8.15 to 6.60 percentage points). Similarly, differential changes were not observed in the secondary outcomes of oxygen switches (DID estimate, -0.04 percentage points; 95% CI, -0.44 to 0.37 percentage points), all-cause mortality (DID estimate, 0.16 percentage points; 95% CI, -7.52 to 7.84 percentage points), all-cause unplanned hospitalizations (DID estimate, -0.20 percentage points; 95% CI, -10.94 to 10.53 percentage points), or COPD hospitalizations (DID estimate, -0.04 percentage points; 95% CI, -2.57 to 2.48 percentage points). Differential changes were observed for mean monthly allowed charges (DID estimate, -$326.22; 95% CI, -$434.76 to -$217.68)., Conclusions and Relevance: In this study, among beneficiaries with COPD, the Medicare CBP was associated with differentially lower spending but not differential changes in oxygen use or clinical outcomes. This study did not find evidence supporting ongoing policy efforts to remove supplemental oxygen from the CBP.

Introduction: A disproportionate share of Federally Qualified Health Center (FQHC) users have a behavioral health condition, but there exists limited research examining changes in behavioral health provision in FQHCs. The objectives of this study were to describe how the provision of behavioral health services by FQHCs to the population of people with behavioral health conditions has changed over time in the US, how these trends varied across states, and whether the proportion of total delivered services that are behavioral health services has changed within FQHCs over time., Methods: Descriptive analysis using the Uniform Data System and Global Burden of Disease Datasets from years 2012 to 2019., Results: From 2012 to 2019, FQHC behavioral health visits per 1,000 population with any behavioral health condition grew 103%, with a 26-fold difference in average rates across states during the study period. Annual behavioral health visits per patient increased from 3.2 to 2012 to 3.4 in 2019. From 2012 to 2019, the number of behavioral health visits per 1,000 FQHC patients grew by 51%, whereas the rate of asthma visits declined by 14%, heart disease visits declined by 4%, and hypertension and diabetes related visits remained stable (changing < 1% for both)., Discussion/conclusion: Behavioral health visit growth at FQHCs outpaced national prevalence of behavioral health conditions. This growth was driven by FQHCs serving an increasing number of patients with behavioral health conditions, without sacrificing the frequency of visits for individual patients with behavioral health conditions., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: To determine the extent to which counting observation stays changes hospital performance on 30-day readmission measures., Methods: This was a retrospective study of inpatient admissions and observation stays among fee-for-service Medicare enrollees in 2017. We generated 3 specifications of 30-day risk-standardized readmissions measures: the hospital-wide readmission (HWR) measure utilized by the Centers for Medicare and Medicaid Services, which captures inpatient readmissions within 30 days of inpatient discharge; an expanded HWR measure, which captures any unplanned hospitalization (inpatient admission or observation stay) within 30 days of inpatient discharge; an all-hospitalization readmission (AHR) measure, which captures any unplanned hospitalization following any hospital discharge (observation stays are included in both the numerator and denominator of the measure). Estimated excess readmissions for hospitals were compared across the 3 measures. High performers were defined as those with a lower-than-expected number of readmissions whereas low performers had higher-than-expected or excess readmissions. Multivariable logistic regression identified hospital characteristics associated with worse performance under the measures that included observation stays., Results: Our sample had 2586 hospitals with 5,749,779 hospitalizations. Observation stays ranged from 0% to 41.7% of total hospitalizations. Mean (SD) readmission rates were 16.6% (5.4) for the HWR, 18.5% (5.7) for the expanded HWR, and 17.9% (5.7) in the all-hospitalization readmission measure. Approximately 1 in 7 hospitals (14.9%) would switch from being classified as a high performer to a low performer or vice-versa if observation stays were fully included in the calculation of readmission rates. Safety-net hospitals and those with a higher propensity to use observation would perform significantly worse., Conclusions: Fully incorporating observation stays in readmission measures would substantially change performance in value-based programs for safety-net hospitals and hospitals with high rates of observation stays., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate whether Medicare's Hospital Readmissions Reduction Program (HRRP) is associated with increased observation stay use., Data Sources and Study Setting: A nationally representative sample of fee-for-service Medicare claims, January 2009-September 2016., Study Design: Using a difference-in-difference (DID) design, we modeled changes in observation stays as a proportion of total hospitalizations, separately comparing the initial (acute myocardial infarction, pneumonia, heart failure) and subsequent (chronic obstructive pulmonary disease) target conditions with a control group of nontarget conditions. Each model used 3 time periods: baseline (15 months before program announcement), an intervening period between announcement and implementation, and a 2-year post-implementation period, with specific dates defined by HRRP policies., Data Collection/extraction Methods: We derived a 20% random sample of all hospitalizations for beneficiaries continuously enrolled for 12 months before hospitalization (N = 7,162,189)., Principal Findings: Observation stays increased similarly for the initial HRRP target and nontarget conditions in the intervening period (0.01% points per month [95% CI -0.01, 0.3]). Post-implementation, observation stays increased significantly more for target versus nontarget conditions, but the difference is quite small (0.02% points per month [95% CI 0.002, 0.04]). Results for the COPD analysis were statistically insignificant in both policy periods., Conclusions: The increase in observation stays is likely due to other factors, including audit activity and clinical advances., (© 2023 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Aligning with Washington State's goal of reducing unnecessary emergency department (ED) use and improving linkage to outpatient primary and behavioral health care, this study evaluated whether an Emergency Department Information Exchange (EDIE) improved linkage to care for Medicaid enrollees with mental health conditions. Follow-up with any physician at 30 days increased slightly, although mental health-specific follow-up declined over time. Difference-in-differences estimates revealed no effect of EDIE on linkage to care after an ED visit. Medicaid beneficiaries with mental health needs and high utilization of the ED likely require additional support to increase timely and appropriate follow-up care.

The emergency department serves as a vital source of health care for residents in the United States, including as a safety net. However, patients from minoritized racial and ethnic groups have historically experienced disproportionate barriers to accessing health care services and lower quality of services than White patients. Quality measures and their application to quality improvement initiatives represent a critical opportunity to incentivize health care systems to advance health equity and reduce health disparities. Currently, there are no nationally recognized quality measures that track the quality of emergency care delivery by race and ethnicity and no published frameworks to guide the development and prioritization of quality measures to reduce health disparities in emergency care. To address these gaps, the American College of Emergency Physicians (ACEP) convened a working group of experts in quality measurement, health disparities, and health equity to develop guidance on establishing quality measures to address racial and ethnic disparities in the provision of emergency care. Based on iterative discussion over 3 working group meetings, we present a summary of existing emergency medicine quality measures that should be adapted to track racial and ethnic disparities, as well as a framework for developing new measures that focus on disparities in access to emergency care, care delivery, and transitions of care., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Importance: Decreases in 30-day readmissions following the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP) have occurred against the backdrop of increasing hospital observation stay use, yet observation stays are not captured in readmission measures., Objective: To examine whether the HRRP was associated with decreases in 30-day readmissions after accounting for observation stays., Design, Setting, and Participants: This retrospective cohort study included a 20% sample of inpatient admissions and observation stays among Medicare fee-for-service beneficiaries from January 1, 2009, to December 31, 2015. Data analysis was performed from November 2021 to June 2022. A differences-in-differences analysis assessed changes in 30-day readmissions after the announcement of the HRRP and implementation of penalties for target conditions (heart failure, acute myocardial infarction, and pneumonia) vs nontarget conditions under scenarios that excluded and included observation stays., Main Outcomes and Measures: Thirty-day inpatient admissions and observation stays., Results: The study included 8 944 295 hospitalizations (mean [SD] age, 78.7 [8.2] years; 58.6% were female; 1.3% Asian; 10.0% Black; 2.0% Hispanic; 0.5% North American Native; 85.0% White; and 1.2% other or unknown). Observation stays increased from 2.3% to 4.4% (91.3% relative increase) of index hospitalizations among target conditions and 14.1% to 21.3% (51.1% relative increase) of index hospitalizations for nontarget conditions. Readmission rates decreased significantly after the announcement of the HRRP and returned to baseline by the time penalties were implemented for both target and nontarget conditions regardless of whether observation stays were included. When only inpatient hospitalizations were counted, decreasing readmissions accrued into a -1.48 percentage point (95% CI, -1.65 to -1.31 percentage points) absolute reduction in readmission rates by the postpenalty period for target conditions and -1.13 percentage point (95% CI, -1.30 to -0.96 percentage points) absolute reduction in readmission rates by the postpenalty period for nontarget conditions. This reduction corresponded to a statistically significant differential change of -0.35 percentage points (95% CI, -0.59 to -0.11 percentage points). Accounting for observation stays more than halved the absolute decrease in readmission rates for target conditions (-0.66 percentage points; 95% CI, -0.83 to -0.49 percentage points). Nontarget conditions showed an overall greater decrease during the same period (-0.76 percentage points; 95% CI, -0.92 to -0.59 percentage points), corresponding to a differential change in readmission rates of 0.10 percentage points (95% CI, -0.14 to 0.33 percentage points) that was not statistically significant., Conclusions and Relevance: The findings of this study suggest that the reduction of readmissions associated with the implementation of the HRRP was smaller than originally reported. More than half of the decrease in readmissions for target conditions appears to be attributable to the reclassification of inpatient admission to observation stays.

Medicaid enrollees with behavioral health disorders often experience fragmented care, leading to high rates of preventable use of emergency departments (EDs). As part of its Medicaid Transformation Program, the Washington Health Care Authority partnered with regional accountable communities of health to collect data on behavioral health integration in community health centers. Clinics who participated in the integrated care demonstration received technical and financial support to increase capacity for integration. This column describes results from an analysis that linked clinic surveys to Medicaid claims to explore characteristics of highly integrated clinics and assess whether clinic capacity for behavioral health integration is associated with ED visit frequency.

Importance: In the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, which found antibiotics to be noninferior, approximately half of participants randomized to receive antibiotics had outpatient management with hospital discharge within 24 hours. If outpatient management is safe, it could increase convenience and decrease health care use and costs., Objective: To assess the use and safety of outpatient management of acute appendicitis., Design, Setting, and Participants: This cohort study, which is a secondary analysis of the CODA trial, included 776 adults with imaging-confirmed appendicitis who received antibiotics at 25 US hospitals from May 1, 2016, to February 28, 2020., Exposures: Participants randomized to antibiotics (intravenous then oral) could be discharged from the emergency department based on clinician judgment and prespecified criteria (hemodynamically stable, afebrile, oral intake tolerated, pain controlled, and follow-up confirmed). Outpatient management and hospitalization were defined as discharge within or after 24 hours, respectively., Main Outcomes and Measures: Outcomes compared among patients receiving outpatient vs inpatient care included serious adverse events (SAEs), appendectomies, health care encounters, satisfaction, missed workdays at 7 days, and EuroQol 5-dimension (EQ-5D) score at 30 days. In addition, appendectomy incidence among outpatients and inpatients, unadjusted and adjusted for illness severity, was compared., Results: Among 776 antibiotic-randomized participants, 42 (5.4%) underwent appendectomy within 24 hours and 8 (1.0%) did not receive their first antibiotic dose within 24 hours, leaving 726 (93.6%) comprising the study population (median age, 36 years; range, 18-86 years; 462 [63.6%] male; 437 [60.2%] White). Of these participants, 335 (46.1%; site range, 0-89.2%) were discharged within 24 hours, and 391 (53.9%) were discharged after 24 hours. Over 7 days, SAEs occurred in 0.9 (95% CI, 0.2-2.6) per 100 outpatients and 1.3 (95% CI, 0.4-2.9) per 100 inpatients; in the appendicolith subgroup, SAEs occurred in 2.3 (95% CI, 0.3-8.2) per 100 outpatients vs 2.8 (95% CI, 0.6-7.9) per 100 inpatients. During this period, appendectomy occurred in 9.9% (95% CI, 6.9%-13.7%) of outpatients and 14.1% (95% CI, 10.8%-18.0%) of inpatients; adjusted analysis demonstrated a similar difference in incidence (-4.0 percentage points; 95% CI, -8.7 to 0.6). At 30 days, appendectomies occurred in 12.6% (95% CI, 9.1%-16.7%) of outpatients and 19.0% (95% CI, 15.1%-23.4%) of inpatients. Outpatients missed fewer workdays (2.6 days; 95% CI, 2.3-2.9 days) than did inpatients (3.8 days; 95% CI, 3.4-4.3 days) and had similar frequency of return health care visits and high satisfaction and EQ-5D scores., Conclusions and Relevance: These findings support that outpatient antibiotic management is safe for selected adults with acute appendicitis, with no greater risk of complications or appendectomy than hospital care, and should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care., Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Importance: For adults with appendicitis, several randomized clinical trials have demonstrated that antibiotics are an effective alternative to appendectomy. However, it remains unknown how the characteristics of patients in such trials compare with those of patients who select their treatment and whether outcomes differ., Objective: To compare participants in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial (RCT) with a parallel cohort study of participants who declined randomization and self-selected treatment., Design, Setting, and Participants: The CODA trial was conducted in 25 US medical centers. Participants were enrolled between May 3, 2016, and February 5, 2020; all participants were eligible for at least 1 year of follow-up, with all follow-up ending in 2021. The randomized cohort included 1094 adults with appendicitis; the self-selection cohort included patients who declined participation in the randomized group, of whom 253 selected appendectomy and 257 selected antibiotics. In this secondary analysis, characteristics and outcomes in both self-selection and randomized cohorts are described with an exploratory analysis of cohort status and receipt of appendectomy., Interventions: Appendectomy vs antibiotics., Main Outcomes and Measures: Characteristics among participants randomized to either appendectomy or antibiotics were compared with those of participants who selected their own treatment., Results: Clinical characteristics were similar across the self-selection cohort (510 patients; mean age, 35.8 years [95% CI, 34.5-37.1]; 218 female [43%; 95% CI, 39%-47%]) and the randomized group (1094 patients; mean age, 38.2 years [95% CI, 37.4-39.0]; 386 female [35%; 95% CI, 33%-38%]). Compared with the randomized group, those in the self-selection cohort were less often Spanish speaking (n = 99 [19%; 95% CI, 16%-23%] vs n = 336 [31%; 95% CI, 28%-34%]), reported more formal education (some college or more, n = 355 [72%; 95% CI, 68%-76%] vs n = 674 [63%; 95% CI, 60%-65%]), and more often had commercial insurance (n = 259 [53%; 95% CI, 48%-57%] vs n = 486 [45%; 95% CI, 42%-48%]). Most outcomes were similar between the self-selection and randomized cohorts. The number of patients undergoing appendectomy by 30 days was 38 (15.3%; 95% CI, 10.7%-19.7%) among those selecting antibiotics and 155 (19.2%; 95% CI, 15.9%-22.5%) in those who were randomized to antibiotics (difference, 3.9%; 95% CI, -1.7% to 9.5%). Differences in the rate of appendectomy were primarily observed in the non-appendicolith subgroup., Conclusions and Relevance: This secondary analysis of the CODA RCT found substantially similar outcomes across the randomized and self-selection cohorts, suggesting that the randomized trial results are generalizable to the community at large., Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Objective: To assess the effects of a program mandating the statewide adoption of an Emergency Department Information Exchange (EDIE) on health care utilization and spending among Medicaid enrollees in Washington state., Data Source: Medicaid claims and managed care encounters from the Washington Health Care Authority., Study Design: A difference-in-differences analysis with trends was used to compare changes in ED visits, inpatient admissions, primary care visits, and expenditures among frequent ED users (≥5 ED visits in past year) to those of infrequent users through the second year Washington's program., Data Extraction: The study population included adult Medicaid enrollees with ED visits between January 2010 and October 2014., Principal Findings: There were 505,667 ED visits among 153,543 unique enrollees included in the analysis. Washington's program was associated with a small, but statistically significant differential change of -0.70 ED visits per enrollee per year (95% CI: -1.24, -0.16) in the first year after EDIE was mandated, or 8.2% of the baseline ED visit rate among frequent users. However, by the second year of implementation, these effects on ED use were no longer significant, nor were there any measurable effects on inpatient admissions, primary care use, or expenditures in any period., Conclusions: Statewide implementation of EDIE was associated with a small reduction in ED use among frequent users in the first year of the program but did not change overall spending or other utilization outcomes., (© 2022 Health Research and Educational Trust.)

Background: Patients with mental illness have been shown to receive lower quality of care and experience worse cardiovascular (CV) outcomes compared to those without mental illness. This present study examined mental health-related disparities in CV outcomes after an Emergency Department (ED) visit for chest pain., Methods: This retrospective cohort included adult Medicaid beneficiaries in Washington state discharged from the ED with a primary diagnosis of unspecified chest pain in 2010-2017. Outcomes for patients with any mental illness (any mental health diagnosis or mental-health specific service use within 1 year of an index ED visit) and serious mental illness (at least two claims (on different dates of service) within 1 year of an index ED visit with a diagnosis of schizophrenia, other psychotic disorder, or major mood disorder) were compared to those of patients without mental illness. Our outcomes of interest were the incidence of major adverse cardiac events (MACE) within 30 days and 6 months of discharge of their ED visit, defined as a composite of death, acute myocardial infarction (AMI), CV rehospitalization, or revascularization. Secondary outcomes included cardiovascular diagnostic testing (diagnostic angiography, stress testing, echocardiography, and coronary computed tomography (CT) angiography) rates within 30 days of ED discharge. Only treat-and-release visits were included for outcomes assessment. Hierarchical logistic random effects regression models assessed the association between mental illness and the outcomes of interest, controlling for age, gender, race, ethnicity, Elixhauser comorbidities, and health care use in the past year, as well as fixed year effects., Results: There were 98,812 treat-and-release ED visits in our dataset. At 30 days, enrollees with any mental illness had no differences in rates of MACE (AOR 0.96; 95% CI, 0.72-1.27) or any of the individual components. At 6 months, enrollees with any mental illness (AOR 1.86; 95% CI, 1.11-3.09) and serious mental illness (AOR 2.60; 95% CI 1.33-5.13) were significantly more likely to be hospitalized for a CV condition compared to those without mental illness. Individuals with any mental illness had higher rates of testing at 30 days (AOR 1.16; 95% CI 1.07-1.27)., Conclusion: Patients with mental illness have similar rates of MACE, but higher rates of certain CV outcomes, such as CV hospitalization and diagnostic testing, after an ED visit for chest pain., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Importance: Uninsured people uniquely rely on the emergency department (ED) for care as they are less likely to have access to lower-cost alternatives. Prior work has demonstrated that most uninsured patients are at risk of catastrophic health expenditure (CHE) after being hospitalized for life-saving care. The risk of CHE for a single treat-and-release ED visit that does not result in a hospitalization among uninsured patient encounters is currently unknown., Objective: To estimate the overall national risk of CHE among uninsured patients after a single treat-and-release ED visit from 2006 through 2017, and to characterize this risk across key traits., Design Setting and Population: This cross-sectional study is based on a nationally representative sample of hospital-based ED visits between 2006 and 2017 in the United States (US) from the Nationwide Emergency Department Sample (NEDS). It examined outpatient ED visits among uninsured patients., Main Outcomes and Measures: Risk of CHE for ED care defined as an ED charge that exceeds 40% of one's estimated annual post-subsistence income., Results: From 2006 to 2017, there were 41.7 million NEDS encounters that met inclusion criteria for this analysis, equating to a nationally weighted estimate of 184.6 million uninsured treat-and-release ED encounters over this period. The median ED charge for a single treat-and-release encounter grew from $842 in 2006 to $2033 by 2017. Approximately 1 in 5 uninsured patients (18% [95% CI, 18.0%-18.0%]) were at risk of CHE for a single treat-and-release ED visit over the study period. This estimated CHE risk increased from 13.6% (95% CI, 13.6%-13.6%) in 2006 to 22.6% (95% CI, 22.6%-22.7%) in 2017. Those living in the lowest income quartile faced a disproportionate share of this risk, with nearly 1 in 3 (28.5% [95% CI, 28.5%-28.6%]) facing CHE risk in 2017. In 2017, an estimated 3.2 million patient encounters nationally were at risk of CHE after a single treat-and-release ED visit., Conclusions and Relevance: This cross-sectional analysis from 2006 to 2017 of 184.6 million uninsured treat-and-release visits found that 1 in 5 uninsured patient encounters are at risk for CHE. This risk has grown over time. Future policies designed to improve access for unscheduled care must consider the unique role of the ED as the de facto safety net and ensure that uninsured patients are not at undue risk of financial harm for seeking care., Competing Interests: Conflict of Interest Disclosures: Dr K. Scott reported grants from Emergency Medicine Foundation—Society for Academic Emergency Medicine Foundation (EMF-SAEMF) during the conduct of the study. Dr J. Scott reported grants from the Agency for Healthcare Research and Quality and personal fees from BCBS of Michigan during the conduct of the study and salary support from Blue Cross Blue Shield of Michigan through the collaborative quality initiative known as Michigan Social Health Interventions to Eliminate Disparities (MSHIELD) outside the submitted work. Dr Dieleman reported grants from Peterson Center on Healthcare and grants from Gates Ventures during the conduct of the study. No other disclosures were reported., (Copyright 2021 Scott KW et al. JAMA Health Forum.)

Objectives: To describe trends in abuse, misuse, and suicide attempts involving diphenhydramine (DPH)., Methods: We analyzed intentional DPH exposures of individuals ≥10 years old reported to U.S. Poison Control Centers using data from the National Poison Data System, 2005-2016., Results: There were 158,774 intentional DPH exposures in our dataset. The rate of intentional exposures increased 63% over the 12-year study period for all ages combined. Suicide attempts involving DPH showed a bimodal distribution-increasing 263% among children 10-14 years of age, and 126 and 143% among those 55-64 and ≥65 years of age, respectively. Older adults in both the 55-64 and ≥65-year-old age groups had about a 230% increase in rates of misuse. Major adverse clinical effects increased by 91%. There were 745 total reported deaths with a 3.6% increase across all age groups., Conclusions: Intentional DPH exposures among individuals ≥10 years old have been increasing since 2005. Increasing rates of suicide attempts among children ages 10-14 and increasing misuse among individuals ≥65, coupled with a trend toward greater severity of overdoses, highlight the significant public health impact of this commonly available over-the-counter drug.

Background: Healthcare spending in the emergency department (ED) setting has received intense focus from policymakers in the United States (U.S.). Relatively few studies have systematically evaluated ED spending over time or disaggregated ED spending by policy-relevant groups, including health condition, age, sex, and payer to inform these discussions. This study's objective is to estimate ED spending trends in the U.S. from 2006 to 2016, by age, sex, payer, and across 154 health conditions and assess ED spending per visit over time., Methods and Findings: This observational study utilized the National Emergency Department Sample, a nationally representative sample of hospital-based ED visits in the U.S. to measure healthcare spending for ED care. All spending estimates were adjusted for inflation and presented in 2016 U.S. Dollars. Overall ED spending was $79.2 billion (CI, $79.2 billion-$79.2 billion) in 2006 and grew to $136.6 billion (CI, $136.6 billion-$136.6 billion) in 2016, representing a population-adjusted annualized rate of change of 4.4% (CI, 4.4%-4.5%) as compared to total healthcare spending (1.4% [CI, 1.4%-1.4%]) during that same ten-year period. The percentage of U.S. health spending attributable to the ED has increased from 3.9% (CI, 3.9%-3.9%) in 2006 to 5.0% (CI, 5.0%-5.0%) in 2016. Nearly equal parts of ED spending in 2016 was paid by private payers (49.3% [CI, 49.3%-49.3%]) and public payers (46.9% [CI, 46.9%-46.9%]), with the remainder attributable to out-of-pocket spending (3.9% [CI, 3.9%-3.9%]). In terms of key groups, the majority of ED spending was allocated among females (versus males) and treat-and-release patients (versus those hospitalized); those between age 20-44 accounted for a plurality of ED spending. Road injuries, falls, and urinary diseases witnessed the highest levels of ED spending, accounting for 14.1% (CI, 13.1%-15.1%) of total ED spending in 2016. ED spending per visit also increased over time from $660.0 (CI, $655.1-$665.2) in 2006 to $943.2 (CI, $934.3-$951.6) in 2016, or at an annualized rate of 3.4% (CI, 3.3%-3.4%)., Conclusions: Though ED spending accounts for a relatively small portion of total health system spending in the U.S., ED spending is sizable and growing. Understanding which diseases are driving this spending is helpful for informing value-based reforms that can impact overall health care costs., Competing Interests: The authors have declared that no competing interests exist.

Background: The extent to which the COVID-19 pandemic has affected outcomes for patients with unplanned hospitalizations is unclear., Objective: To examine changes in in-hospital mortality for patients without COVID-19 during the first 10 months of the pandemic (March 4, 2020 to December 31, 2020)., Design, Setting, and Participants: Observational study of adults with unplanned hospitalizations at 51 hospitals across 6 Western states., Exposures: Unplanned hospitalizations occurring during the spring COVID-19 surge (March 4 to May 13, 2020; Period 1), an intervening period (May 14 to October 19, 2020; Period 2), and the fall COVID-19 surge (October 20 to December 31, 2020; Period 3) were compared with a pre-COVID-19 baseline period from January 1, 2019, to March 3, 2020., Main Outcomes and Measures: We examined daily hospital admissions and in-hospital mortality overall and in 30 conditions., Results: Unplanned hospitalizations declined steeply during Periods 1 and 3 (by 47.5% and 25% compared with baseline, respectively). Although volumes declined, adjusted in-hospital mortality rose from 2.9% in the pre-pandemic period to 3.5% in Period 1 (20.7% relative increase), returning to baseline in Period 2, and rose again to 3.4% in Period 3. Elevated mortality was seen for nearly all conditions studied during the pandemic surge periods., Conclusion: Pandemic COVID-19 surges were associated with higher rates of in-hospital mortality among patients without COVID-19, suggesting disruptions in care patterns for patients with many common acute and chronic illnesses.

Background: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis., Methods: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith., Results: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50)., Conclusions: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.)., (Copyright © 2020 Massachusetts Medical Society.)

Study Objective: Observation stays are composing an increasing proportion of unscheduled hospitalizations in the United States, with unclear consequences for the quality of care. This study used a nationally representative data set of commercially insured patients hospitalized from the emergency department (ED) to compare 30-day postdischarge unplanned care events after an observation stay versus a short inpatient admission., Methods: This was a retrospective analysis of ED hospitalizations using the 2015 Truven MarketScan Commercial Claims and Encounters data set. Adult observation stays and short inpatient hospitalizations of 2 days or less were identified and followed for 30 days from hospital discharge to identify unplanned care events, defined as a subsequent inpatient admission, observation stay, or return ED visit. A propensity score analysis was used to compare rates of unplanned events after each type of index hospitalization., Results: Among the propensity-weighted cohorts, patients with an index observation stay were 28% more likely to experience any unplanned care event within 30 days of discharge compared with those with a short inpatient admission (20.4% versus 15.9%; risk ratio 1.28; 95% confidence interval [CI] 1.21 to 1.34). Specifically, patients in the observation stay group had substantially higher rates of postdischarge observation stays (4.8% versus 1.9%; odds ratio 2.60; 95% CI 2.15 to 3.16) and ED revisits with discharge (11.1% versus 8.8%; odds ratio 1.26; 95% CI 1.21 to 1.44) compared with those in the inpatient group, but were less likely to be readmitted as inpatients (6.4% versus 7.2%; odds ratio 0.90; 95% CI 0.83 to 0.96)., Conclusion: Commercially insured patients with an observation stay from the ED have a higher risk of postdischarge acute care events compared with similar patients with a short inpatient admission. Additional research is necessary to determine the extent to which quality of care, including care transitions, may differ between these 2 groups., (Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Recent attention has been given to developing measures to capture the quality of ED transitions of care. We examined the utility of a patient-reported measure of transitional care, the Care Transitions Measure-3 (CTM-3), in the ED setting and its association with outcomes of care after ED discharge., Methods: A telephone survey was conducted of a convenience sample of patients 14 days after discharge from two emergency departments (EDs) in an academic health system. Patients responded to three statements using a four-point agreement scale (strongly disagree, disagree, agree, strongly agree): 1) "The hospital staff took my preferences and those of my family or caregiver into account when deciding what my health care needs would be"; 2) " When I left the ER, I had a good understanding of the things I was responsible for in managing my health"; and 3) "When I left the hospital, I clearly understood the purpose for taking each of my medications." Patients were also queried about outcomes after ED discharge that are known to be related to ED care transitions including medication adherence, completion of recommended follow-up, and return visits to the ED. Multivariable logistic regression was used to determine the association between the CTM-3 score (on a 100-point scale) and outcomes of interest., Results: Among 1,832 patients called, 576 were reached by phone, and 410 consented and completed our survey, representing a 22.4% response rate of patients we attempted to call. A 10-point increase in the CTM-3 score (better care experiences) was associated with a 12% decrease in the odds of having an ED return visit (adjusted odds ratio [AOR] = 0.88, 95% confidence interval [CI] = 0.77-1.00) and a 45% increase in the odds of taking prescribed medications as recommended (AOR = 1.45, 95% CI = 1.12-1.87). There was no association between CTM-3 score and completion of follow-up., Conclusions: The CTM-3 is associated with outcomes of care after an ED visit, including ED return visits and medication adherence, and may have utility as a patient-reported measure of ED transitions of care., (© 2018 by the Society for Academic Emergency Medicine.)

Objective: To examine trends in the use of ED observation stays among a national sample of patients with commercial insurance, and assess the patient cost-burden of an observation stay relative to an short inpatient hospitalization from the ED., Methods: Retrospective analysis of ED observation stays and inpatient hospitalizations from 2008 to 2015 using the Truven MarketScan® Commercial Claims and Encounters database. Index ED visits were identified from claims files and assessed for evidence of an observation or inpatient hospitalization. Total and out-of-pocket costs were calculated for the index hospitalization and a 30-day episode of care and standardized to 2015 $USD. Costs for ED patients with an observation stay were compared to a similar, propensity-matched cohort of ED patients hospitalized as inpatients., Results: Over the 8 year period, observation stay admissions increased from 4.3% to 6.8% of total ED visits (60.5% relative increase) while inpatient admissions fell from 10.8% to 8.9% (16.6% relative decrease). In 2015, the mean total cost was $8162 for an observation stay and $22,865 for an inpatient hospitalization. Patient out-of-pocket costs were $962 and $1403, respectively. Among the propensity-matched cohorts, relative mean costs for the index hospitalization were 41% higher and patient out-of-pocket costs were 33% higher if the patient was admitted as an inpatient from the ED versus observation during their hospitalization., Conclusions: Observation hospitalizations are an increasingly common disposition for patients entering the hospital through the ED. Both total and patient out-of-pocket costs are lower, on average, for an observation stay compared with a similar inpatient admission for ED patients requiring hospitalization., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The objective was to test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit., Methods: This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as "ED return admissions" (discharged at ED index visit and admitted at return visit) or "readmissions" (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to "index admissions without return admission" (admitted at ED index visit without 7-day return visit admission)., Results: Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = -$193; 95% CI = -$479 to $93) compared to index admissions without return admission., Conclusions: Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions., (© 2017 by the Society for Academic Emergency Medicine.)

Introduction: Several European studies suggest that some patients with appendicitis can be treated safely with antibiotics. A portion of patients eventually undergo appendectomy within a year, with 10%-15% failing to respond in the initial period and a similar additional proportion with suspected recurrent episodes requiring appendectomy. Nearly all patients with appendicitis in the USA are still treated with surgery. A rigorous comparative effectiveness trial in the USA that is sufficiently large and pragmatic to incorporate usual variations in care and measures the patient experience is needed to determine whether antibiotics are as good as appendectomy., Objectives: The Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial for acute appendicitis aims to determine whether the antibiotic treatment strategy is non-inferior to appendectomy., Methods/analysis: CODA is a randomised, pragmatic non-inferiority trial that aims to recruit 1552 English-speaking and Spanish-speaking adults with imaging-confirmed appendicitis. Participants are randomised to appendectomy or 10 days of antibiotics (including an option for complete outpatient therapy). A total of 500 patients who decline randomisation but consent to follow-up will be included in a parallel observational cohort. The primary analytic outcome is quality of life (measured by the EuroQol five dimension index) at 4 weeks. Clinical adverse events, rate of eventual appendectomy, decisional regret, return to work/school, work productivity and healthcare utilisation will be compared. Planned exploratory analyses will identify subpopulations that may have a differential risk of eventual appendectomy in the antibiotic treatment arm., Ethics and Dissemination: This trial was approved by the University of Washington's Human Subjects Division. Results from this trial will be presented in international conferences and published in peer-reviewed journals., Trial Registration Number: NCT02800785., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: Transitional care clinics (TCCs) represent one strategy to facilitate follow-up and primary care linkage for patients with no regular source of care who are discharged from the emergency department (ED). We assessed factors associated with completion of TCC follow-up among these patients and characterized their subsequent ED use., Methods: Retrospective study of 660 randomly sampled patients with a scheduled appointment to a TCC at time of ED discharge. Patient- and visit-level characteristics were abstracted from the medical records of these patients and linked to a state visit database to characterize ED use after referral. Multiple logistic regression was used to determine factors associated with completion of follow-up and subsequent ED utilization., Results: Half (50%) of the patients completed their follow-up appointment with a mean follow-up time of 6.9days. Non-English language (odds ratio [OR], 2.21; confidence interval [CI], 1.30-3.75) was the only factor associated with improved follow-up; however, patients who were homeless (OR, 0.42; CI, 0.26-0.66) had a substance use history (OR, 0.68; CI, 0.45-1.00), and those with more baseline ED visits (OR, 0.94 per additional ED visit; CI, 0.89-0.99) were significantly less likely to complete follow-up. After adjusting for demographic, clinical, and visit-level characteristics, patients who completed their appointment had significantly fewer ED visits in the subsequent year compared to patients who did not complete their appointment (mean, 2.3 vs 3.3 visits; difference, -1.0 visits in subsequent calendar year; CI for difference, -1.2 to -0.7)., Conclusion: Transitional care clinics represent a promising strategy to improve the continuity of care for emergency patients and may reduce unnecessary ED use., (Published by Elsevier Inc.)

Importance: Unscheduled short-term return visits to the emergency department (ED) are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care., Objective: To examine in-hospital clinical outcomes and resource use among patients who are hospitalized during an unscheduled return visit to the ED., Design, Setting, and Participants: Retrospective analysis of adult ED visits to acute care hospitals in Florida and New York in 2013 using data from the Healthcare Cost and Utilization Project. Patients with index ED visits were identified and followed up for return visits to the ED within 7, 14, and 30 days., Exposures: Hospital admission occurring during an initial visit to the ED vs during a return visit to the ED., Main Outcomes and Measures: In-hospital mortality, intensive care unit (ICU) admission, length of stay, and inpatient costs., Results: Among the 9,036,483 index ED visits to 424 hospitals in the study sample, 1,758,359 patients were admitted to the hospital during the index ED visit. Of these patients, 149,214 (8.5%) had a return visit to the ED within 7 days of the index ED visit, 228,370 (13.0%) within 14 days, and 349,335 (19.9%) within 30 days, and 76,151 (51.0%), 122,040 (53.4%), and 190,768 (54.6%), respectively, were readmitted to the hospital. Among the 7,278,124 patients who were discharged during the index ED visit, 598,404 (8.2%) had a return visit to the ED within 7 days, 839,386 (11.5%) within 14 days, and 1,205,865 (16.6%) within 30 days. Of these patients, 86,012 (14.4%) were admitted to the hospital within 7 days, 121,587 (14.5%) within 14 days, and 173,279 (14.4%) within 30 days. The 86,012 patients discharged from the ED and admitted to the hospital during a return ED visit within 7 days had significantly lower rates of in-hospital mortality (1.85%) compared with the 1,609,145 patients who were admitted during the index ED visit without a return ED visit (2.48%) (odds ratio, 0.73 [95% CI, 0.69-0.78]), lower rates of ICU admission (23.3% vs 29.0%, respectively; odds ratio, 0.73 [95% CI, 0.71-0.76]), lower mean costs ($10,169 vs $10,799; difference, $629 [95% CI, $479-$781]), and longer lengths of stay (5.16 days vs 4.97 days; IRR, 1.04 [95% CI, 1.03-1.05]). Similar outcomes were observed for patients returning to the ED within 14 and 30 days of the index ED visit. In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit., Conclusions and Relevance: Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay. These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.

Patient-centered emergency diagnostic imaging relies on efficient communication and multispecialty care coordination to ensure optimal imaging utilization. The construct of the emergency diagnostic imaging care coordination cycle with three main phases (pretest, test, and posttest) provides a useful framework to evaluate care coordination in patient-centered emergency diagnostic imaging. This article summarizes findings reached during the patient-centered outcomes session of the 2015 Academic Emergency Medicine consensus conference "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The primary objective was to develop a research agenda focused on 1) defining component parts of the emergency diagnostic imaging care coordination process, 2) identifying gaps in communication that affect emergency diagnostic imaging, and 3) defining optimal methods of communication and multidisciplinary care coordination that ensure patient-centered emergency diagnostic imaging. Prioritized research questions provided the framework to define a research agenda for multidisciplinary care coordination in emergency diagnostic imaging., (© 2015 by the Society for Academic Emergency Medicine.)

Study Objective: Although numerous studies have demonstrated a relationship between higher volume and improved outcomes in the delivery of health services, it has not been extensively explored in the emergency department (ED) setting. Therefore, we seek to examine the association between ED hospitalization volume and mortality for common high-risk conditions., Methods: Using data from the Nationwide Inpatient Sample, a national sample of hospital discharges, we evaluated mortality overall and for 8 different diagnoses between 2005 and 2009 (total admissions 17.55 million). These conditions were chosen because they are frequent (in the top 25 of all ED hospitalizations) and high risk (> 3% observed mortality). EDs were excluded from analysis if they did not have at least 1,000 total annual admissions and 30 disease-specific cases. EDs were then placed into quintiles based on hospitalized volume. Regression techniques were used to describe the relationship between volume (number of hospitalized ED patients per year) and both subsequent early inpatient mortality (within 2 days of admission) and overall mortality, adjusted for patient and hospital characteristics., Results: Mortality decreased as volume increased overall and for all diagnoses, but the relative importance of volume varied, depending on the condition. Absolute differences in adjusted mortality rates between very high-volume EDs and very low-volume EDs ranged from -5.6% for sepsis (95% confidence interval [CI] -6.5% to -4.7%) to -0.2% for pneumonia (95% CI -0.6% to 0.1%). Overall, this difference was -0.4% (95% CI -0.6% to -0.3%). A similar pattern was observed when early hospital deaths were evaluated., Conclusion: Patients have a lower likelihood of inhospital death if admitted through high-volume EDs., (Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

The emergency department (ED) is now the primary source for hospitalizations in the United States, and admission rates for all causes differ widely between EDs. In this study we used a national sample of ED visits to examine variation in risk-standardized hospital admission rates from EDs and the relationship of this variation to inpatient mortality for the fifteen most commonly admitted medical and surgical conditions. We then estimated the impact of variation on national health expenditures under different utilization scenarios. Risk-standardized admission rates differed substantially across EDs, ranging from 1.03-fold for sepsis to 6.55-fold for chest pain between the twenty-fifth and seventy-fifth percentiles of the visits. Conditions such as chest pain, soft tissue infection, asthma, chronic obstructive pulmonary disease, and urinary tract infection were low-mortality conditions that showed the greatest variation. This suggests that some of these admissions might not be necessary, thus representing opportunities to improve efficiency and reduce health spending. Our data indicate that there may be sizeable savings to US payers if differences in ED hospitalization practices could be narrowed among a few of these high-variation, low-mortality conditions., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Physicians have dual responsibilities to make medical decisions that serve their patients' best interests but also utilize health care resources wisely. Their ability to practice cost-consciously is particularly challenged when faced with patient expectations or requests for medical services that may be unnecessary., Objective: To understand how physicians consider health care resources and the strategies they use to exercise cost-consciousness in response to patient expectations and requests for medical care., Design: Exploratory, qualitative focus groups of practicing physicians were conducted. Participants were encouraged to discuss their perceptions of resource constraints, and experiences with redundant, unnecessary and marginally beneficial services, and were asked about patient requests or expectations for particular services., Participants: Sixty-two physicians representing a variety of specialties and practice types participated in nine focus groups in Michigan, Ohio, and Minnesota in 2012 MEASUREMENTS: Iterative thematic content analysis of focus group transcripts, Principal Findings: Physicians reported making trade-offs between a variety of financial and nonfinancial resources, considering not only the relative cost of medical decisions and alternative services, but the time and convenience of patients, their own time constraints, as well as the logistics of maintaining a successful practice. They described strategies and techniques to educate patients, build trust, or substitute less costly alternatives when appropriate, often adapting their management to the individual patient and clinical environment., Conclusions: Physicians often make nuanced trade-offs in clinical practice aimed at efficient resource use within a complex flow of clinical work and patient expectations. Understanding the challenges faced by physicians and the strategies they use to exercise cost-consciousness provides insight into policy measures that will address physician's roles in health care resource use.

Background: In the face of escalating spending, measuring and maximizing the value of health services has become an important focus of health reform. Recent initiatives aim to incentivize high-value care through provider and hospital payment reform, but the role of the emergency department (ED) remains poorly defined., Objectives: To achieve an improved understanding of the value of emergency care, we have developed a framework that incorporates the perspectives of stakeholders in the delivery of health services., Methods: A pragmatic review of the literature informed the design of this framework to standardize the definition of value in emergency care and discuss outcomes and costs from different stakeholder perspectives. The viewpoint of patient, provider, payer, health system, and society is each used to assess value for emergency medical conditions., Results: We found that the value attributed to emergency care differs substantially by stakeholder perspective. Potential targets to improve ED value may be aimed at improving outcomes or controlling costs, depending on the acuity of the clinical condition., Conclusion: The value of emergency care varies by perspective, and a better understanding is achieved when specific outcomes and costs can be identified, quantified, and measured. Using this framework can help stakeholders find common ground to prioritize which costs and outcomes to target for research, quality improvement efforts, and future health policy impacting emergency care., (Copyright © 2014 Elsevier Inc. All rights reserved.)