Prehospital Emergency Care
ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Acceptability of Alternatives to Traditional Emergency Care: Patient Characteristics, Alternate Transport Modes, and Alternate Destinations Courtney Marie Cora Jones PhD, MPH, Erin B. Wasserman BA, Timmy Li BA, EMT-B & Manish N. Shah MD, MPH To cite this article: Courtney Marie Cora Jones PhD, MPH, Erin B. Wasserman BA, Timmy Li BA, EMT-B & Manish N. Shah MD, MPH (2015) Acceptability of Alternatives to Traditional Emergency Care: Patient Characteristics, Alternate Transport Modes, and Alternate Destinations, Prehospital Emergency Care, 19:4, 516-523, DOI: 10.3109/10903127.2015.1025156 To link to this article: http://dx.doi.org/10.3109/10903127.2015.1025156
Published online: 22 May 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipec20 Download by: [University of Florida]
Date: 06 November 2015, At: 03:28
ACCEPTABILITY OF ALTERNATIVES TO TRADITIONAL EMERGENCY CARE: PATIENT CHARACTERISTICS, ALTERNATE TRANSPORT MODES, AND ALTERNATE DESTINATIONS Courtney Marie Cora Jones, PhD, MPH, Erin B. Wasserman, BA, Timmy Li, BA, EMT-B, Manish N. Shah, MD, MPH
Downloaded by [University of Florida] at 03:28 06 November 2015
ABSTRACT
illness severity (p < 0.05). In our ED, some patients found alternative transport modes and alternative destinations acceptable. We identified patient-level characteristics associated with willingness to accept alternatives; however, the predictive ability and clinical utility of these factors is limited. Future research should further explore the acceptability and effectiveness of these alternative care delivery options. Key words: emergency medical services, alternate destinations, emergency care, healthcare delivery
To determine the acceptability of alternatives to traditional emergency care, we assessed the proportion of subjects willing to consider alternative modes of transportation and alternative destinations. We further identified patient characteristics associated with willingness to consider these alternatives. We conducted a cross-sectional survey study in the emergency department (ED) of an academic medical center. Research assistants screened all noncritically ill ED patients for eligibility and willingness to participate and administered an interview-based survey that included questions on demographic and clinical characteristics, perceived illness severity, and acceptability of alternatives to traditional emergency care for acute illness and injuries. We calculated the proportions and 95% confidence intervals for subjects who found alternative transport modes and destinations acceptable and developed a log-binomial regression model to identify patient characteristics associated with acceptability of alternative modes of transport and alternative destinations. Complete data were available on 1,058 subjects. Forty-two percent of the study sample arrived to the ED via emergency medical services (EMS). Over two-thirds of the study sample (68.2%) was willing to consider transport via either taxi or medical transport van and 69.0% was willing to consider either transportation to an urgent care center or their primary care physician’s office. Other alternatives, including delayed EMS response time, were less frequently endorsed as acceptable alternatives. Subject characteristics associated with willingness to accept alternative modes of transportation included younger age, chief complaint, previous ED use, and place of residence (p < 0.05). Subject characteristics associated with willingness to accept alternative destinations included younger age, nonwhite race, lower patient acuity, and lower self-perceived
PREHOSPITAL EMERGENCY CARE 2015;19:516–523
BACKGROUND Ambulance-based emergency medical services (EMS) and emergency departments (EDs) serve as a vital component of the healthcare system. However, these systems have experienced increasing demand.1−5 In 1997, the ED visit rate was estimated at 352 visits per 1,000 population and in 2011 this rate increased to 415 visits per 1,000 population.6,7 Similarly, the number of patients arriving to EDs by EMS has increased.8 To meet this increasing demand for acute care and to efficiently deliver safe, high-quality care while reducing strain on the emergency care system, alternatives to the traditional system have been suggested. Proposed options for patients with minor illness or injury have included 1) alternative modes of transport (e.g., via medical transport van); 2) alternative destinations (e.g., urgent care centers (UCCs) or primary care physician (PCP) offices); and 3) distance medical evaluation via novel technologies (e.g., telemedicine).1−3, 9−11
Alternative modes of transportation and alternative destinations to traditional emergency care have many potential benefits to patients and the broader healthcare system. Transporting patients with non-urgent conditions to alternative destinations such as UCCs and PCP offices may reduce burden on busy EDs.11 The ability to provide patients with acute care in familiar settings, such as PCP offices, ensures continuity of care.12 National efforts have been made to prevent special populations, such as older adults, from using EDs for conditions that can be cared for more appropriately and efficiently elsewhere.13−16 Furthermore, the cost of care provided in UCCs or PCP offices for non-urgent conditions is often lower than the cost of ED-based care for the same conditions.17
Received August 5, 2014 from University of Rochester Medical Center, Emergency Medicine, Rochester, New York (CMCJ, EBW, TL, MNS). Revision received January 28, 2015; accepted for publication January 28, 2015. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence to Courtney Marie Cora Jones, PhD, MPH, University of Rochester Medical Center, Emergency Medicine, 601 Elmwood Avenue, Box 655, Rochester, NY 14642, USA. E-mail: Courtney [email protected] doi: 10.3109/10903127.2015.1025156
516
C.M.C. Jones et al.
Although these options may have benefits for the efficiency of overall healthcare delivery, research on patient attitudes toward these alternatives is limited and few studies have rigorously assessed the acceptability of alternatives to traditional EMS and ED care.18,19 The objective of this study was to quantitatively assess the acceptability of various alternatives to traditional emergency care and to identify patient-level characteristics associated with willingness to accept alternative modes of transportation as well as alternative destinations.
METHODS Study Design Downloaded by [University of Florida] at 03:28 06 November 2015
517
ACCEPTABILITY OF EMERGENCY CARE ALTERNATIVES
We conducted a cross-sectional survey study of ED patients from September 2010 to June 2011. The institution’s research subject’s review board approved this study with exempt status and a waiver of documentation of informed consent.
Study Setting and Population This study was conducted in the ED of an 800bed urban academic medical center in the northeastern United States. The ED provides care to approximately 100,000 patients per year and serves as the region’s primary tertiary referral hospital and level I trauma center. It serves patients from a six-county catchment area with a mix of urban, suburban, and rural communities. Inclusion criteria for the study included age ≥ 19 years, having decisional capacity, and the ability to read and understand English. Exclusion criteria included prisoners, residents of psychiatric institutions, psychiatric ED patients, patients who were sedated, critically ill patients as defined by an Emergency Severity Index (ESI) of 1, previous participation in the study, and ED arrival between midnight and 8 a.m. due to availability of research assistant staff. There were no restrictions placed on chief complaint or mode of ED arrival. For the purposes of the current analysis, individuals residing in institutional settings, such as skilled nursing facilities, were excluded because these patients are not fully engaged the decision-making process regarding emergency care services due to facility policies.
Study Protocol All ED patients were screened for eligibility by research assistants (RAs) from September 2010 to June 2011. Information regarding basic demographic and clinical information, including age, sex, chief complaint, mode of ED arrival, and acuity level, was collected by RA staff via the ED electronic medical record
on all screened patients, including those who were not enrolled in the study. Eligible patients were approached by an RA for participation in the study during their ED visit after an initial assessment was performed by an ED provider. An information letter was provided to all potential subjects and the study was described in detail, allowing time for questions. If the potential subject expressed an interest in participation, the RA assessed whether he or she possessed decisional capacity using a standardized instrument previously developed by the study principal investigators (CMCJ and MNS) and approved by the institutional research subjects review board. Consenting subjects were interviewed using a survey designed specifically to address the objectives and hypotheses of this study. The RA also abstracted all enrolled subjects’ ED medical records to obtain clinical information pertaining to their ED visits.
Materials and Measures Two members of the study team (CMCJ and MNS) developed an interview-based survey and a systematic chart review process based on previous research with pediatric patients.19 The survey items and chart review process were modified for use among adult patients. The medical record review was designed to systematically obtain clinical information related to the patient’s ED visit as documented by the ED triage nurse, including the chief complaint for which they were seeking treatment, and acuity level (measured via Emergency Severity Index score). The interview-based survey asked for subjects’ demographic information, past medical history, self-rated health, and mode of ED arrival (EMS vs. other transportation methods). The survey also asked subjects the acceptability of various alternatives to traditional emergency medical care, including delayed EMS response time, transport via taxi, transportation via medical transport van, transport to a UCC, transport to their PCP’s office, no transportation but evaluation via telemedicine, and no transportation but given a PCP appointment within 24 hours (Figure 1). Because we sampled all ED patients, regardless of their chief complaint, acuity level, or mode of ED arrival, this question was purposefully worded to elicit responses to hypothetical future illnesses: “In the future, if you are as sick as you are today, how acceptable would the following be?” The subject was then asked to rate each alternative on a 7-point Likert scale with anchors at values of 1, 4, and 7 (1 = completely unacceptable; 4 = acceptable; 7 = very acceptable). The wording of questions was standardized and a laminated card was shown to all subjects to reference the Likert response options. All RAs were trained to use a standardized definition of each alternative (medical transport van, telemedicine, etc.) in the event the subject asked for clarification.
Downloaded by [University of Florida] at 03:28 06 November 2015
518
PREHOSPITAL EMERGENCY CARE
OCTOBER/DECEMBER 2015
VOLUME 19 / NUMBER 4
FIGURE 1. Alternatives to traditional emergency care survey questions.
The survey was iteratively revised to improve clarity based on feedback received from pre-testing the instrument with content experts and RA staff and pilot-testing with the target population in the ED. The medical record review process was pilot-tested with an RA prior to study initiation.
Data Analysis Data were analyzed using SAS 9.3 (SAS Institute, Cary, NC, USA). The study sample was described using basic descriptive characteristics including proportions and 95% confidence intervals. Characteristics of those who were enrolled and those refusing participation were compared using bivariate analyses. The proportion of subjects who found each alternative acceptable was also calculated. To identify patient characteristics predictive of willingness to accept alternatives to traditional emergency care, two multivariable models were developed. First, outcome variables were collapsed to identify patient factors associated with 1) acceptability of alternatives to EMS transportation (medical transport van and taxi); and 2) acceptability of alternative destinations (UCC and PCP office). The distribution of Likert responses was evaluated for all outcome variables and, due to small sample sizes in the various response categories, both outcome variables were dichotomized into “acceptable” (Likert scale 4–7) and “Unacceptable” (Likert scale 1–3) categories. Variables hypothesized to be predictive of acceptability were identified a priori by the research team
and bivariate analyses were conducted separately with each outcome variable. For both outcomes, a manual model building process was used. All variables significantly associated with acceptability of alternative destinations were entered in a log-binomial regression model. A log-binomial, instead of a logistic, model was used to generate effect estimates for these data due to the cross-sectional nature of the study design and the high prevalence of the outcome variables.20−24 Bivariate analyses were conducted between each potential predictor variable and the outcomes of interest. A more liberal p-value (
ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Acceptability of Alternatives to Traditional Emergency Care: Patient Characteristics, Alternate Transport Modes, and Alternate Destinations Courtney Marie Cora Jones PhD, MPH, Erin B. Wasserman BA, Timmy Li BA, EMT-B & Manish N. Shah MD, MPH To cite this article: Courtney Marie Cora Jones PhD, MPH, Erin B. Wasserman BA, Timmy Li BA, EMT-B & Manish N. Shah MD, MPH (2015) Acceptability of Alternatives to Traditional Emergency Care: Patient Characteristics, Alternate Transport Modes, and Alternate Destinations, Prehospital Emergency Care, 19:4, 516-523, DOI: 10.3109/10903127.2015.1025156 To link to this article: http://dx.doi.org/10.3109/10903127.2015.1025156
Published online: 22 May 2015.
Submit your article to this journal
Article views: 50
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipec20 Download by: [University of Florida]
Date: 06 November 2015, At: 03:28
ACCEPTABILITY OF ALTERNATIVES TO TRADITIONAL EMERGENCY CARE: PATIENT CHARACTERISTICS, ALTERNATE TRANSPORT MODES, AND ALTERNATE DESTINATIONS Courtney Marie Cora Jones, PhD, MPH, Erin B. Wasserman, BA, Timmy Li, BA, EMT-B, Manish N. Shah, MD, MPH
Downloaded by [University of Florida] at 03:28 06 November 2015
ABSTRACT
illness severity (p < 0.05). In our ED, some patients found alternative transport modes and alternative destinations acceptable. We identified patient-level characteristics associated with willingness to accept alternatives; however, the predictive ability and clinical utility of these factors is limited. Future research should further explore the acceptability and effectiveness of these alternative care delivery options. Key words: emergency medical services, alternate destinations, emergency care, healthcare delivery
To determine the acceptability of alternatives to traditional emergency care, we assessed the proportion of subjects willing to consider alternative modes of transportation and alternative destinations. We further identified patient characteristics associated with willingness to consider these alternatives. We conducted a cross-sectional survey study in the emergency department (ED) of an academic medical center. Research assistants screened all noncritically ill ED patients for eligibility and willingness to participate and administered an interview-based survey that included questions on demographic and clinical characteristics, perceived illness severity, and acceptability of alternatives to traditional emergency care for acute illness and injuries. We calculated the proportions and 95% confidence intervals for subjects who found alternative transport modes and destinations acceptable and developed a log-binomial regression model to identify patient characteristics associated with acceptability of alternative modes of transport and alternative destinations. Complete data were available on 1,058 subjects. Forty-two percent of the study sample arrived to the ED via emergency medical services (EMS). Over two-thirds of the study sample (68.2%) was willing to consider transport via either taxi or medical transport van and 69.0% was willing to consider either transportation to an urgent care center or their primary care physician’s office. Other alternatives, including delayed EMS response time, were less frequently endorsed as acceptable alternatives. Subject characteristics associated with willingness to accept alternative modes of transportation included younger age, chief complaint, previous ED use, and place of residence (p < 0.05). Subject characteristics associated with willingness to accept alternative destinations included younger age, nonwhite race, lower patient acuity, and lower self-perceived
PREHOSPITAL EMERGENCY CARE 2015;19:516–523
BACKGROUND Ambulance-based emergency medical services (EMS) and emergency departments (EDs) serve as a vital component of the healthcare system. However, these systems have experienced increasing demand.1−5 In 1997, the ED visit rate was estimated at 352 visits per 1,000 population and in 2011 this rate increased to 415 visits per 1,000 population.6,7 Similarly, the number of patients arriving to EDs by EMS has increased.8 To meet this increasing demand for acute care and to efficiently deliver safe, high-quality care while reducing strain on the emergency care system, alternatives to the traditional system have been suggested. Proposed options for patients with minor illness or injury have included 1) alternative modes of transport (e.g., via medical transport van); 2) alternative destinations (e.g., urgent care centers (UCCs) or primary care physician (PCP) offices); and 3) distance medical evaluation via novel technologies (e.g., telemedicine).1−3, 9−11
Alternative modes of transportation and alternative destinations to traditional emergency care have many potential benefits to patients and the broader healthcare system. Transporting patients with non-urgent conditions to alternative destinations such as UCCs and PCP offices may reduce burden on busy EDs.11 The ability to provide patients with acute care in familiar settings, such as PCP offices, ensures continuity of care.12 National efforts have been made to prevent special populations, such as older adults, from using EDs for conditions that can be cared for more appropriately and efficiently elsewhere.13−16 Furthermore, the cost of care provided in UCCs or PCP offices for non-urgent conditions is often lower than the cost of ED-based care for the same conditions.17
Received August 5, 2014 from University of Rochester Medical Center, Emergency Medicine, Rochester, New York (CMCJ, EBW, TL, MNS). Revision received January 28, 2015; accepted for publication January 28, 2015. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence to Courtney Marie Cora Jones, PhD, MPH, University of Rochester Medical Center, Emergency Medicine, 601 Elmwood Avenue, Box 655, Rochester, NY 14642, USA. E-mail: Courtney [email protected] doi: 10.3109/10903127.2015.1025156
516
C.M.C. Jones et al.
Although these options may have benefits for the efficiency of overall healthcare delivery, research on patient attitudes toward these alternatives is limited and few studies have rigorously assessed the acceptability of alternatives to traditional EMS and ED care.18,19 The objective of this study was to quantitatively assess the acceptability of various alternatives to traditional emergency care and to identify patient-level characteristics associated with willingness to accept alternative modes of transportation as well as alternative destinations.
METHODS Study Design Downloaded by [University of Florida] at 03:28 06 November 2015
517
ACCEPTABILITY OF EMERGENCY CARE ALTERNATIVES
We conducted a cross-sectional survey study of ED patients from September 2010 to June 2011. The institution’s research subject’s review board approved this study with exempt status and a waiver of documentation of informed consent.
Study Setting and Population This study was conducted in the ED of an 800bed urban academic medical center in the northeastern United States. The ED provides care to approximately 100,000 patients per year and serves as the region’s primary tertiary referral hospital and level I trauma center. It serves patients from a six-county catchment area with a mix of urban, suburban, and rural communities. Inclusion criteria for the study included age ≥ 19 years, having decisional capacity, and the ability to read and understand English. Exclusion criteria included prisoners, residents of psychiatric institutions, psychiatric ED patients, patients who were sedated, critically ill patients as defined by an Emergency Severity Index (ESI) of 1, previous participation in the study, and ED arrival between midnight and 8 a.m. due to availability of research assistant staff. There were no restrictions placed on chief complaint or mode of ED arrival. For the purposes of the current analysis, individuals residing in institutional settings, such as skilled nursing facilities, were excluded because these patients are not fully engaged the decision-making process regarding emergency care services due to facility policies.
Study Protocol All ED patients were screened for eligibility by research assistants (RAs) from September 2010 to June 2011. Information regarding basic demographic and clinical information, including age, sex, chief complaint, mode of ED arrival, and acuity level, was collected by RA staff via the ED electronic medical record
on all screened patients, including those who were not enrolled in the study. Eligible patients were approached by an RA for participation in the study during their ED visit after an initial assessment was performed by an ED provider. An information letter was provided to all potential subjects and the study was described in detail, allowing time for questions. If the potential subject expressed an interest in participation, the RA assessed whether he or she possessed decisional capacity using a standardized instrument previously developed by the study principal investigators (CMCJ and MNS) and approved by the institutional research subjects review board. Consenting subjects were interviewed using a survey designed specifically to address the objectives and hypotheses of this study. The RA also abstracted all enrolled subjects’ ED medical records to obtain clinical information pertaining to their ED visits.
Materials and Measures Two members of the study team (CMCJ and MNS) developed an interview-based survey and a systematic chart review process based on previous research with pediatric patients.19 The survey items and chart review process were modified for use among adult patients. The medical record review was designed to systematically obtain clinical information related to the patient’s ED visit as documented by the ED triage nurse, including the chief complaint for which they were seeking treatment, and acuity level (measured via Emergency Severity Index score). The interview-based survey asked for subjects’ demographic information, past medical history, self-rated health, and mode of ED arrival (EMS vs. other transportation methods). The survey also asked subjects the acceptability of various alternatives to traditional emergency medical care, including delayed EMS response time, transport via taxi, transportation via medical transport van, transport to a UCC, transport to their PCP’s office, no transportation but evaluation via telemedicine, and no transportation but given a PCP appointment within 24 hours (Figure 1). Because we sampled all ED patients, regardless of their chief complaint, acuity level, or mode of ED arrival, this question was purposefully worded to elicit responses to hypothetical future illnesses: “In the future, if you are as sick as you are today, how acceptable would the following be?” The subject was then asked to rate each alternative on a 7-point Likert scale with anchors at values of 1, 4, and 7 (1 = completely unacceptable; 4 = acceptable; 7 = very acceptable). The wording of questions was standardized and a laminated card was shown to all subjects to reference the Likert response options. All RAs were trained to use a standardized definition of each alternative (medical transport van, telemedicine, etc.) in the event the subject asked for clarification.
Downloaded by [University of Florida] at 03:28 06 November 2015
518
PREHOSPITAL EMERGENCY CARE
OCTOBER/DECEMBER 2015
VOLUME 19 / NUMBER 4
FIGURE 1. Alternatives to traditional emergency care survey questions.
The survey was iteratively revised to improve clarity based on feedback received from pre-testing the instrument with content experts and RA staff and pilot-testing with the target population in the ED. The medical record review process was pilot-tested with an RA prior to study initiation.
Data Analysis Data were analyzed using SAS 9.3 (SAS Institute, Cary, NC, USA). The study sample was described using basic descriptive characteristics including proportions and 95% confidence intervals. Characteristics of those who were enrolled and those refusing participation were compared using bivariate analyses. The proportion of subjects who found each alternative acceptable was also calculated. To identify patient characteristics predictive of willingness to accept alternatives to traditional emergency care, two multivariable models were developed. First, outcome variables were collapsed to identify patient factors associated with 1) acceptability of alternatives to EMS transportation (medical transport van and taxi); and 2) acceptability of alternative destinations (UCC and PCP office). The distribution of Likert responses was evaluated for all outcome variables and, due to small sample sizes in the various response categories, both outcome variables were dichotomized into “acceptable” (Likert scale 4–7) and “Unacceptable” (Likert scale 1–3) categories. Variables hypothesized to be predictive of acceptability were identified a priori by the research team
and bivariate analyses were conducted separately with each outcome variable. For both outcomes, a manual model building process was used. All variables significantly associated with acceptability of alternative destinations were entered in a log-binomial regression model. A log-binomial, instead of a logistic, model was used to generate effect estimates for these data due to the cross-sectional nature of the study design and the high prevalence of the outcome variables.20−24 Bivariate analyses were conducted between each potential predictor variable and the outcomes of interest. A more liberal p-value (
