Category: Research

Where did all the emergencies go?

published date
April 30th, 2020 by
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Do you need me?

When COVID-19 hit, hospitals knew they would see a decline in elective surgeries and routine visits. After all, they canceled them! But the volume of patients visiting the emergency room has also dropped dramatically, and no one can seem to fully explain it. Sure, maybe we could expect fewer car crashes and skiing injuries. But heart attacks and strokes? If anything it seems like those numbers should be going up due to higher stress levels. Yet, the analyses in cardiac care during the pandemic show a sharp decline not only in elective cardiac procedures, but also in cardiac catheterizations for acute heart attacks, specifically, those with ST segment elevations – the most life threatening type.  

Conventional wisdom tells us that the drop in ER visits is a bad thing. Patients must be dying at home, outcomes must be worsening, and the patients that do survive will show up as train wrecks once the pandemic subsides. Those assumptions are probably true to a certain extent, but the open question is how true?   Acute conditions and complications warrant acute care.  But in the routine care of behavioral health and other chronic conditions such as diabetes and hypertension, extensive overuse of the emergency room rather than other ambulatory settings has been a prime area of concern and debate for several years.  

We know that ERs are overused in normal times. And we think they’re underused now during the pandemic, but to what extent should be analyzed and debated as we inform the necessary adaptation of our systems of care.  We expect to see an incredible amount of variation in ER utilization as the situation unfolds, by specific patient populations, urban vs rural settings, and geography-specific COVID-19 case burden. 

We are encouraged that Datavant has convened a wide variety of industry players to construct a COVID-19 Research Database, a set of de-identified data sets made freely available to enable rapid studies at scale.  The new initiative fills an important gap between quick observations that are available from small sets of real world data and clinical trials, which are robust but slow.

The ER phenomenon we’re discussing is not completely unprecedented. Researchers (and ER staff) have long observed the ‘big game effect’ – where ER visits decline as people defer them to watch their favorite team. (The Health Business Blog first reported on it in 2005: Red Sox’ success eases health care crisis.) Some, but not all, of those visits are avoided entirely without negative consequences. The COVID-19 pandemic provides an opportunity for a much longer time series. Let’s use it as a chance to study what’s going on so we can apply the lessons learned as we emerge.

What could explain sustained, lower utilization of the ER? There are a few possibilities:

  1. Many seemingly serious problems resolve on their own when people just wait. If people avoid the ER out of fear, the ‘tincture of time’ will often do the job.
  2. Less aggressive ambulatory settings are proving effective: the physician’s office, a telehealth visit, or home remedies.
  3. The momentum and logic of the ER setting makes matters seem more serious than they really are. Once someone appears there’s always something to find. (As a doctor colleague once told me, “Show me someone who’s perfectly healthy and I’ll give him a full workup to demonstrate otherwise.”)
  4. The ER is the entry point for admission to the hospital. Under fee for service, hospitals need to admit patients to make money. Depending on the proportion of available beds during these uncertain times, hospitals may be even more economically motivated than usual to fill open beds. So, once a patient arrives, they may be staying.
  5. A significant portion of ER traffic is composed of so-called ‘frequent fliers.’ Usually, they are tolerated, but in the current environment, ER staff are motivated to triage non-COVID-19 patients away from the hospital as efficiently as possible. Once this becomes evident, the ‘frequent fliers’ ground themselves.
  6. How many times have you called your doctor’s office or pharmacy and heard the recording say, “If this is a medical emergency, hang up and dial 9-1-1”? That definitely got people used to the idea that the ER is a good place for care. Clearly people are ignoring that messaging now!

So what should we do with this unexpected information?

  1. More finely tune financial incentives to discourage unneeded utilization while not discouraging needed care. We know from experience that bluntly requiring large patient financial contributions drive down both good and bad utilization.
  2. Educate people about the downside of ER visits (infection risk, treatment that’s too aggressive, likelihood of admission to hospital, provider that doesn’t know you) to balance out the current bias for ER care. People will be more receptive now and won’t immediately think that health plans are only trying to ration their care. 
  3. Consider other changes in benefit design to help the decreased utilization persist, including increased access and reimbursement for home services, telehealth, and remote management tools.
  4. Encourage physician offices and others to make better efforts to intervene quickly and prevent people from going to the ER just for convenience. This could include on-demand availability of telehealth consultations and other digital/remote management for which they would be reimbursed.

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By healthcare business consultant David E. Williams, president of Health Business Group and Surya Singh MD, president of Singh Healthcare Advisors.

Coronavirus: We are all in this together

published date
March 20th, 2020 by

In this edition of #CareTalk, Carecentrix CEO John Driscoll and I discuss the impact of COVID-19 in the US and around the world.  John retracts his earlier claim that the feds are doing a good job, and we go on to discuss the fact that we’re all in this together, universal coverage is a sensible policy, science matters, and government can help.

We agree with Tony Fauci, who said, “If it looks like you’re overreacting, you’re probably doing the right thing,” and we also look for signs of hope on the horizon (or just over it).


By healthcare business consultant David E. Williams, president of Health Business Group.

Health disparities: You ain’t seen nothing yet

published date
January 22nd, 2020 by
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Welcome to the machine

A survey in the UK showed that the gap in health between rich and poor is widening. From the US perspective that comes as a bit of a surprise. After all, don’t the Brits have universal healthcare through the NHS?

But of course, social determinants of health such as diet, exercise, stress, access to transportation, and education play a bigger role in health than the healthcare system. With socioeconomic disparities widening, it serves to reason that health disparities will grow, too.

So where do things go from here? They probably get worse –that’s my guess. Current political and economic forces in the US, UK and elsewhere point toward an exacerbation of current gaps. And as climate change makes the world a generally harsher environment it’s the poor who will be more adversely affected by floods, fires, air pollution, etc.

But in a decade or two that will be nothing compared with the haves and have nots wrought by the advancement of medical technology. Expect the well off to increasingly invest in tools that let them get further ahead: for example cyborg inventions that augment intelligence, strength, vision, hearing and more. Not to mention artificial organs and genetic interventions to greatly extend life.

Will such modifications make people happy? Maybe not. But it will enable them to lord it over the rest of society to an increasingly greater degree.

Enjoy!

What gets measured gets done. So be careful what you measure!

published date
October 21st, 2019 by

When I read ‘Fear of Falling’: How Hospitals Do Even More Harm By Keeping Patients in Bed I was reminded of the old adage, ‘What gets measured gets done.’

In this video I lay out three solutions to the problem of overzealous pursuit of fall reduction:

  1. Keep the measure but change the target so we’re not aiming for zero falls
  2. Add a new measure of how much patients are getting up and walking
  3. Reduce the penalties for excessive falls

What do you think?

By healthcare business consultant David E. Williams, president of Health Business Group.

Noisy hand dryers – how to cope? Hint: Lower you hands

published date
July 25th, 2019 by
fullerton02
Noisemaker in chief
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Noise reduction nozzles. Anyone ever seen one of these in the wild?

Nora Louise Keegan, a 13 year old Canadian has generated great publicity with her recent article in Pediatrics & Child Health (Children who say hand dryers ‘hurt my ears’ are correct: A real-world study examining the loudness of automated hand dryers in public places).

She conducted a rigorous study to measure the peak loudness of dryers at two distances from the wall, both with and without hands in the dryer’s air flow. She measured the sounds at different heights, corresponding to the ear canal height of younger and older kids and of adult men and women.

I encourage you to read the article. It is brief and well-written.

When I saw the write-up in the Washington Post, I immediately remembered writing about this very issue back in 2013 (when the author was about 7 and starting to develop an interest in the topic).

In my post (Hand hygiene and hearing loss. Avoiding the tradeoff) I wrote:

I’m not so fond of the Excel Xlerator. Sure it’s powerful, but it’s also incredibly noisy. I have sensitive ears, and I’m not embarrassed to admit that when I’m exposed to a loud sound I cover my ears with my hands. But of course if I’m drying my hands I can’t use them to protect from the noise. The Xlerator is loud enough that I suspect it’s a threat to hearing. At the very least it’s so annoying that I bet some people skip hand washing to avoid using it. My gym has one of these beasts and after being bothered by it for a while I decided to research the noise level.

I didn’t do any original research but I found a paper by Jeffrey Fullerton and a colleague from an acoustical consulting firm and corresponded with Jeff about the subject. He told me that the airstream is a major factor in the noise level and advised me to lower my hands a foot or so below the nozzle , which helps make things quieter. This is the approach I use to this day, with some success –although sometimes the sensor doesn’t see my hands and it does take a bit longer to dry.

The new research by Keegan quantifies the difference made by placing hands in the airflow and also identified the Xlerator as the number one bad boy.

When I read the article I circled back to my original sources. The article I cited is gone (maybe the firm snuffed it when the author moved on) but the Acoustical Society of America still has a summary on its site.

My favorite tidbit is that there is (was?) a noise reduction nozzle for the Xlerator. Presumably the manufacturer understood there was a problem.

I’ve never seen one of these in use. Have you?

By healthcare business consultant David E. Williams, president of Health Business Group.