Emergency Medicine

Summary by Website Contributor Willis Schuerger

 

Emergency medicine (EM) has shown sporadic success with P4P initiatives, but EM’s high patient volumes, wide range of acuity, and intrinsic interconnectedness to other specialties presents unique challenges as well. Reporting on large scale, government funded P4P programs Cheng (468, 475) and Vermeulen (470) show that P4P may shorten patient’s average ED length of stay (LOS). On a smaller scale, and in privately run hospitals, Butcher (473) suggests P4P can improve physician productivity and patient satisfaction in the ED. A major challenge when designing EM P4P plans, however, is determining what metrics best describe ED success. Schuur (471, 474) criticizes the frequent usage of LOS as a primary metric for EM P4P programs (468, 470, 475), noting a failure of that metric to address broader systems issues in hospitals which cause ED LOS to be long. Schuur (474), in particular, argues for a more longitudinal perspective on patients’ relationship with the ED. Glickman (469) attempts to implement an interdisciplinary P4P program, recognizing that outcomes for patients who start in the ED are frequently dependent on many other specialties as well. As it stands at the beginning of 2020, there have been a number of studies suggesting promise for the future use of P4P in emergency medicine, but also significant pushback, primarily centered around the need for quality metrics that go beyond LOS and recognize the interconnectedness of the specialty.

Emergency Medicine Literature

Key Article

(168) Glickman SW, Schulman KA, Peterson ED, Hocker MB, Cairns CB. Evidence-Based Perspectives on Pay for Performance and Quality of Patient Care and Outcomes in Emergency Medicine. Annals of Emergency Medicine. 2008: 51(5) 622-631.

PMID: 18358566

Summary:

  • Article reviews the 9 emergency care performance metrics and grades them based on the American College of Cardiology and American Heart Association criteria for selection of performance measures to improve quality.
  • 5 of the 9 emergency measures meet all four of the criteria.
  • Authors suggest 2 new performance measures that should be used.
  • Quality improvement initiatives in emergency medicine would benefit greatly from large research networks.

Significance to Literature:

Overview of the P4P measures in Emergency medicine.

(468) Citation: Cheng AH, Sutherland JM. British Columbia's pay-for-performance experiment: part of the solution to reduce emergency department crowding?. Health Policy. 2013;113(1-2):86-92.

PMID: 24216028

Summary:

  • An examination of the effects of a provincial pay for performance program on emergency department (ED) length of stay (LOS) times around the greater Vancouver area between 2009 and 2012.
  • The results are mixed. Some hospitals improved during the study period, particularly if they were teaching hospitals. Other hospitals showed little change, or even some decline.
  • Hospitals were paid $100 per patient for meeting discharge home LOS, and $600 per patient for meeting admission LOS goals. (1% of typical hospital budget)

Significance to Literature:

P4P can help reduce ED LOS, particularly in academic medical centers. Given P4P’s variable impact in this study, a closer examination of program design factors may help distinguish elements that determine success.

 

(469) Citation: Glickman SW, Ou FS, Delong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA. 2007;297(21):2373-80.

PMID: 17551130

Summary:

  • An examination of the Myocardial Infarction (MI) component of the Hospital Quality Incentive Demonstration launched in 2003 by the Centers for Medicare and Medicaid Services (CMS).
  • This paper took data from 105,383 patients with non-ST-segment elevation MIs enrolled in participating hospitals over a 3 year period. In total 6 CMS process measures and 8 non-CMS measures were used to evaluate the treatment of these patients. Of those, 3 of the CMS measures and 3 of the non-CMS measures were primarily emergency department (ED) responsibilities.
  • The data showed significant improvement in only 2 of the 6 CMS measures, and 1 of the 8 non-CMS measures, none of which were those performed in the ED.
  • The authors conclude that the overall effect of the P4P  pilot did not significantly improve outcomes for MI patients, but that it also caused no adverse effects for those patients.

Significance to Literature:

This article describes an early attempt at implementing a large scale performance based incentives program in the US. It focuses on a condition that is treated across many departments and specialties, which makes it difficult to interpret for just emergency medicine, but perhaps is more true to how hospitals really function in the treatment of patients.

 

(470) Citation: Vermeulen MJ, Stukel TA, Boozary AS, Guttmann A, Schull MJ. The Effect of Pay for Performance in the Emergency Department on Patient Waiting Times and Quality of Care in Ontario, Canada: A Difference-in-Differences Analysis. Ann Emerg Med. 2016;67(4):496-505.e7.

PMID: 26215670

Summary:

  • A retrospective examination of emergency department (ED) visits in Ontario hospitals between 2007 and 2011. This study includes both P4P hospitals and control hospitals.
  • The study examines three separate “waves” in which P4P Length of Stay (LOS) goals were implemented in Ontario hospitals.
  • Three waves of LOS reduction goals were rolled out in temporal succession and were calculated at 5%, 10%, and 15% relative to each hospital’s baseline LOS.
  • All payments were given in full upfront, and then subject to recovery if the goals were not met. None of the money provided could be used to supplement physician incomes.
  • All three waves reduced ED LOS, but achieved mixed success in meeting the 5%, 10%, and 15% thresholds. The greatest reductions in LOS came from hospitals with the poorest baseline LOS (given LOS reduction goals were a % of initial baseline LOS).
  • No unintended consequences resulted from the programs.

Significance to Literature:

A large scale P4P ED LOS study demonstrated positive effect without unintended consequences. An example of rewarding improvement vs achievement given success was calculated by % improvement from baseline performance. A novel P4P design included up-front payments subject to reclamation and a ban on using the funds for physician incomes.

 

(471) Citation: Schuur JD, Venkatesh AK. The Price of Waiting: What Can a Province Buy for $109 Million?. Ann Emerg Med. 2016;67(4):506-8.

PMID: 26803702

Summary:

  • A critique of the findings presented in Verm[3]
  • This article praises some features of the P4P program, particularly the use of a payment up front with threat of return.
  • Authors argue that although statistically significant, results did not demonstrate a clinically significant reduction in ED LOS.
  • The authors go on to argue a meaningful reduction in ED LOS times would have been nearly impossible to achieve, because wait times are symptoms of other, larger systems-based problems including the availability of inpatient beds.

Significance to Literature:

This rebuttal argues that directly targeting ED LOS (a popular metric for ED quality improvement programs) is unlikely to produce clinically significant results, because it does not address underlying larger structural causes.

 

(472) Citation: Wiler JL, Granovsky M, Cantrill SV, Newell R, Venkatesh AK, Schuur JD. Physician Quality Reporting System Program Updates and the Impact on Emergency Medicine Practice. West J Emerg Med. 2016;17(2):229-37.

PMID: 26973757

Summary:

  • A detailed examination of the 2015 expanded Physician Quality Reporting System (PQRS) and Qualified Clinical Data Registry (QCDR) as they relate to ED physicians. Breaks down penalties and benefits, reporting options, and ED specific CMS quality measures that were cut or kept.
    • Discusses the difficulty for small ED physician practices to meet reporting requirements, and the viability of the Measure Applicability Validation (MAV).
  • Describes the 2015 introduction of the Value Modifier (VM) program for physician payment and its effect on emergency medicine.
    • VM is a national, zero-sum incentive program that ranks performance based on quality and cost of care, and rewards or punishes physician groups by comparing them to a constructed mean standard for their specialty.
  • Discusses the possible future of federal pay for performance incentives in the US, particularly the beginning of the Merit-Based Incentive Payment System (MIPS).

Significance to Literature:

This article provides a detailed snapshot of what federal P4P programs looked like for emergency medicine physicians immediately before and after the 2015 overhaul - serves as historical reference as the precursor of MIPS.

 

(473) Citation: Butcher L. Physicians. ED docs motivated by performance-based pay. Hosp Health Netw. 2011;85(11):10.

PMID: 22195435

Summary:

  • A journalistic article describing a P4P program implemented at The hospital of Central Connecticut in 2005.
  • The program gave all emergency department (ED) physicians the same base salary with the opportunity to improve it by up to 30% based on their productivity and patient satisfaction scores. The program also included individualized remediation plans and subsequent disciplinary (asked to leave) actions for physicians who did not meet certain ED quality standards in any given quarter.
  • Prior to the program’s launch in 2005 patient satisfaction scores were below the 70th percentile. Between 2005 and 2010, those scores were consistently above the 80th percentile, and at times reached as high as the 99th percentile.

Significance to Literature:

This case study shows increased productivity and patient satisfaction following the implementation of significant P4P incentives on ED physician salaries and individualized remediation plans. Unanticipated consequences were not studied.

 

(474) Citation: Schuur JD, Hsia RY, Burstin H, Schull MJ, Pines JM. Quality measurement in the emergency department: past and future. Health Aff (Millwood). 2013;32(12):2129-38.

PMID: 24301396

Summary:

  • An overview of emergency department (ED) quality measurement; what has been done, what is being done, and recommendations for the future.
  • Many programs measure and incentivize LOS for ED patients. This metric can be arbitrary, and often leads to gaming numbers in order to meet strict mandates.
  • The future of quality measurement in the ED will require improvement in 3  main areas:
    1. Development of new ways to measure the effectiveness and quality of care
    2. Research into care coordination, regionalization, and episodic cost
    3. Emphasis on the longitudinal relationship of a patient with the ED, not just on any single visit they may have.

Significance to Literature:

Any P4P initiative will only be as good as the metrics it uses. This article critiques a number of common measurements used frequently in ED quality improvement, and offers recommendations on how future programs could improve.

 

(475) Citation: Cheng I, Taylor D, Schull MJ, et al. Comparison of emergency department time performance between a Canadian and an Australian academic tertiary hospital. Emerg Med Australas. 2019;31(4):605-611.

PMID: 30811092

Summary:

  • A comparison of P4P initiatives in a Canadian and an Australian hospital, both intended to reduce emergency department (ED) LOS
    • The Canadian hospital was part of a P4P initiative in Ontario for EDs with volumes >30,000. 70% of the funding was for current LOS performance, and 30% was for improvement from the program start date.
    • The Australian hospital was part of the National Emergency Access Target (NEAT), a program that offered funding for hospital projects and improvements if they could keep 75% of all ED visits £ 4 hours.
  • Over four years both hospitals failed to meet their respective standards. In that time the Canadian hospital showed no significant improvement, but the Australian hospital did increase the number of patients with LOS £ 4hrs by 10%.
  • There were several major structural differences in the two locations that heavily contributed to their outcomes. In particular, wider hospital resources such as bed count, specialist availability, and imaging capabilities were key components in meeting time goals.
    • Patient population characteristics (especially complexity of care required) and time to initial physician assessment were also significant to outcomes.
    • The authors note, “important factors are mainly clinical resources. Increasing output resources made a greater impact on shortening ED LOS than input-throughput interventions.”

Significance to Literature:

This article provides a direct comparison of two hospitals using P4P to decrease LOS, but with very different challenges due to the differing characteristics of each hospital. Identifies several key factors (many non-ED related) that determine whether P4P can reduce ED LOS.