The National Report Card on the State of Emergency Medicine
2009; Elsevier BV; Volume: 53; Issue: 6 Linguagem: Inglês
10.1016/j.annemergmed.2008.12.004
ISSN1097-6760
AutoresB.S. Heavrin, Tyler W. Barrett, David L. Schriger,
Tópico(s)Patient Satisfaction in Healthcare
Resumo1Emergency department (ED) crowding, boarding, and hospital diversion have been negatively associated with multiple patient care measures (time to antibiotics, analgesic administration, etc).A. How might hospital diversion and ED boarding be deleterious to resident education?B. Might these same factors affect medical students' decision to choose emergency medicine as a career?2The composite grade for each state consisted of ratings in 5 specific areas: access to emergency care, medical liability environment, quality and patient safety, public health and injury prevention, and disaster preparedness.A. How were the measures weighted relative to one another?B. What does the weighting suggest about the importance of each category?C. Is this a fair and consistent weighting?D. How does it compare with previous Report Cards?E. What additional measures would you like incorporated into the 2012 Report Card?3A. Why publish a Report Card on the state of emergency care?B. What utility does it serve to policymakers, payers, providers, and the public?C. Substantial variation exists among states in each of the 5 categories that compose a grade. Discuss the factors within the Report Card that best explain this variation. Consider metrics at the patient, provider, and regulatory levels.4A. The Report Card gives Massachusetts the highest overall state grade and Arkansas the lowest overall grade. Compare Massachusetts and Arkansas across the 5 categories used to assign a grade.B. Which categories most clearly show why Massachusetts outperforms Arkansas?C. Are there any metrics in which Arkansas outperforms Massachusetts?D. How should one interpret this head-to-head comparison, and what caveats exist for such comparisons?5A. The panel makes 8 core recommedations according to the results of the Report Card. How might a policymaker interpret these recommendations?B. What are the barriers at the state and federal level to implementing such reforms? Q1.a Emergency department (ED) crowding, boarding, and hospital diversion have been negatively associated with multiple patient care measures (time to antibiotics, analgesic administration, etc). How might hospital diversion and ED boarding be deleterious to resident education? The Institute of Medicine Report concluded that ED crowding is contributing to a “national crisis in emergency care” and recommended that hospitals stop boarding admitted patients in the ED.1Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemHospital-Based Emergency Care: At the Breaking Point. National Academies Press, Washington, DC2006Google Scholar During the past 3 years, more than 20 articles have been published on ED crowding and boarding and the harmful effects on patient care and physician well-being.2Pines J.M. Hollander J.E. Emergency department crowding is associated with poor care for patients with severe pain.Ann Emerg Med. 2008; 51: 1-5Abstract Full Text Full Text PDF PubMed Scopus (363) Google Scholar, 3Pines J.M. Localio A.R. Hollander J.E. et al.The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia.Ann Emerg Med. 2007; 50: 517-519Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar, 4Diercks D.B. Roe M.T. Chen A.Y. et al.Prolonged emergency department stays of non-ST-segment elevation myocardial infarction patients are associated with worse adherence to the ACC/AHA guidelines for management and increased adverse events.Ann Emerg Med. 2007; 50: 489-496Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Schull M.J. Vermeulen M. Slaughter G. et al.Emergency department crowding and thrombolysis delays in acute myocardial infarction.Ann Emerg Med. 2004; 44: 577-585Abstract Full Text Full Text PDF PubMed Scopus (328) Google Scholar, 6Fishman P.E. Shofer F.S. Robey J.L. et al.The impact of trauma activations on the care of ED patients with potential acute coronary syndromes.Ann Emerg Med. 2006; 48: 347-354Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 7McConnell K.J. Richards C.F. Daya M. et al.Effect of increased ICU capacity on emergency department length of stay and ambulance diversion.Ann Emerg Med. 2005; 45: 471-478Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 8Derlet R.W. Overcrowding in emergency departments: increased demand and decreased capacity.Ann Emerg Med. 2002; 39: 430-432Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar, 9American Academy of Emergency MedicineAAEM position statement on emergency department crowding May 25, 2005.http://www.aaem.org/positionstatements/crowding.phpGoogle Scholar In 2005, Atzema et al10Atzema C. Bandiera G. Schull M.J. et al.Emergency department crowding: the effect on resident education.Ann Emerg Med. 2005; 45: 276-281Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar detailed crowding's effect on resident education and provided recommendations for maximizing learning in an crowded environment. ED crowding can be detrimental to resident education in several ways that are noted below and then considered in turn. Residents and medical students generally learn more by evaluating new patients than observing stable admitted patients. When beds are occupied by boarding patients, fewer new patients are treated each shift. Faculty, distracted by the need to manage the crowding, may have less time to teach. The unpleasant work environment created by crowding may not be conducive to thoughtful discussions about patient care. The evaluation and management of critically ill patients is a vital component of resident education. EDs that close to ambulance traffic because of crowding will treat fewer critically ill medical patients,7McConnell K.J. Richards C.F. Daya M. et al.Effect of increased ICU capacity on emergency department length of stay and ambulance diversion.Ann Emerg Med. 2005; 45: 471-478Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar resulting in fewer medical resuscitations for residents. McConnell et al7McConnell K.J. Richards C.F. Daya M. et al.Effect of increased ICU capacity on emergency department length of stay and ambulance diversion.Ann Emerg Med. 2005; 45: 471-478Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar showed that when an ICU increased staffing, the number of diversion days decreased and there was an 18% increase in ICU admissions from the ED. Crowding may necessitate that faculty devote greater attention to administrative flow issues.11Wolfe R. The effects of ED overcrowding on EM education Lunch session: SAEM annual meeting, 2003.http://www.saem.org/meetings/03handouts/wolfe.pdfGoogle Scholar Despite this concern, recent single-center surveys report that instructors continue to teach well despite the crowding challenge.12Kelly S.P. Shapiro N. Woodruff M. et al.The effects of clinical workload on teaching in the emergency department.Acad Emerg Med. 2007; 14: 526-531Crossref PubMed Google Scholar, 13Hoxhaj S. Moseley M.G. Siler Fisher A. et al.Resident education does not correlate with the degree of emergency department crowding.Ann Emerg Med. 2004; 44: S77Abstract Full Text PDF Google Scholar Although these articles are encouraging, this issue requires continued attention. The American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), and Council of Emergency Residency Directors have focused on developing solutions to the crowding and resident education problem. There was a “Teaching Innovations on Coping with Crowding” abstract contest at the 2008 Scientific Assembly. The Council of Emergency Residency Directors had small group discussions on crowding and education at the 2008 Council of Emergency Residency Directors Academic Assembly. The Society for Academic Emergency Medicine has a dedicated “Emergency Medicine and Hospital Crowding” section on its Web site.14Ankel F. Howes D. Lin M. et al.ED crowding on education: blessing or curse?.http://www.saem.org/saemdnn/Advocacy/CrowdingAdvocacy/tabid/1160/Default.aspxGoogle Scholar Many EDs have instituted alternative triage systems to expedite the disposition of low-acuity patients and identify potentially unstable waiting room patients.15Choi Y.F. Wong T.W. Lau C.C. et al.Triage Rapid Initial Assessment by Doctor (TRIAD) improves waiting time and processing time of the emergency department.Emerg Med J. 2006; 23: 262-265Crossref PubMed Scopus (88) Google Scholar, 16Subash F. Dunn F. McNicholl B. et al.Team triage improves emergency department efficiency.Emerg Med J. 2004; 21: 542-544Crossref PubMed Scopus (105) Google Scholar Although these strategies might improve ED patient throughput time, the effect of stationing faculty at triage on resident education is not known. When faculty enter orders on patients or diagnose a patient's complaint in triage, junior residents miss the opportunity to consider that complaint's differential diagnosis. Senior residents will not have the chance to improve their efficiency if faculty at triage screen and discharge low-acuity patients directly from the waiting room. Alternatively, faculty triage and discharge of nonemergency patients from the waiting room increases the number of acutely ill patients transported to examination rooms for resident evaluation. The effect of ED crowding and the boarding of admitted patients on resident and medical student education is still under investigation. However, these challenging times should encourage emergency medicine faculty and residents to improve their teaching and learning skills to maximize educational interactions despite potentially fewer opportunities. Q1.b Might these same factors affect medical students' decision to choose emergency medicine as a career? Emergency medicine continues to be a highly sought-after specialty for graduating medical students. Despite an increase in the total number of emergency medicine spots by 111 to 1,475 postgraduate year 1 and 2 positions in 2008, 97.9% of emergency medicine residency positions were filled. The overall percentage of graduating US senior medical students who enter emergency medicine has increased from 6.7% in 2006 to 7.5% in 2008.17National Resident Matching Program Advance data tables for the 2008 main residency match.2008http://www.nrmp.org/data/advancedatatables2008.pdfGoogle Scholar According to these data, crowding has not deterred medical students from choosing emergency medicine as a career. However, ambulance diversion and the boarding of admitted patients will negatively affect medical students' emergency medicine experience. The onus is on faculty and senior emergency medicine residents to overcome these obstacles and highlight emergency medicine's unique advantages. Since its inception, emergency medicine has continually adapted to new challenges. As ACEP President Nick Jouriles, MD, wrote in a recent editorial, the overflowing waiting rooms and ambulance diversion need to be eliminated so that emergency medicine can continue to attract the “best and brightest” medical students.18Jouriles N. Work hard, have fun Overachieve.Ann Emerg Med. 2008; 52: 314-316Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Q2.a The composite grade for each state consisted of ratings in 5 specific areas: access to emergency care, medical liability environment, quality and patient safety, public health and injury prevention, and disaster preparedness. How were the measures weighted relative to one another? Access to emergency care (30%) The quality and patient safety environment (20%) Public health and injury prevention (15%) Medical liability environment (20%) Disaster preparedness (15%) Q2.b What does the weighting suggest about the importance of each category? Report Card Task Force members assigned weights that reflect their beliefs about each measure's importance to the overall state of emergency medicine. Therefore, the task force considered the category of “Access to Emergency Care” twice as influential to the overall grade as “Public Health and Injury Prevention” and “Disaster Preparedness.” The Report Card Task Force assigned specific weights to individual metrics within each of the 5 primary categories. Q2.c Is this a fair and consistent weighting? To evaluate the fairness of the weighting and scoring system, one must understand how the grades were calculated. Report Card Task Force members developed the weightings by a consensus process, the specifics of which are presented on pages 126 to 128 of the Technical Appendix. A few details of the weighting and scoring process are worthy of comment: 1) Scoring method The individual items (indicators) that make up a category are scored in the following ways: Continuous variables: State's values are placed in numeric order. The best state is assigned 100% of that indicator's weight and the worst a zero. States in between are assigned a fractional score according to their rank order. For example, a state that ranked 10th best would be given 42/51 of the indicator's weight; a state that ranked 50th best, 1/51 of the indicator's weight. Binary variables: Each state that has a “yes” is given the full weight for the indicator. Each state that has a “no” for the item is given a zero. Consequence: Regardless of its intent, this system tends to emphasize binary items over continuous items. A state that just missed a “yes” on a categorical item gets zero credit, whereas one that barely made a “yes” gets full credit. On a continuous item, such states would receive scores that are very similar (say 26/51 vesus 33/51 of the indicator). Furthermore, the use of ranks for continuous indicators blunts any large differences achieved by the best or worst states. For example, the best state could have a result 10 times greater than the next best state, yet it would receive a score of 51/51 of the indicator's weight, whereas the next best state would receive 50/51. As a result of these scoring rules, separation among states has greater dependence on the binary items. 2) Grading method A state's grade for a category is determined as follows: The indicator scores for that category are summed for each state. The mean and SD of the 51 resulting scores (one for each state) are calculated (regardless of the shape of the distribution of scores). The state with the highest score (regardless of where that score falls in the range of possible scores) is given an A, as are all states within .5 SDs of that score. States with means 0.5 to 0.75 SD below the high score are given a score of A–, states from 0.75 to 1.0 SD are given a B+, and so on. Consequence: First, even if the best state scored 5 out of 100 possible points for a category, it would be given an A because it was the best state. Therefore, the grades have greater meaning as comparators than they do as absolute measures of quality. Second, if scores are not distributed in a bell-shaped distribution or are bell shaped but platykurtic (excessively wide) or leptokurtic (excessively narrow), then letter grades will be oddly distributed. For example, if the best state was 2.5 SDs higher than any other state and all the other states were bunched within 0.25 SD of one another (one high outlier), then the grades would be 1 A and 50 D–'s. Such oddities could create category scores and hence overall scores whose values do not represent the intent of the task force. Thus, there are oddities about the scoring system that could create scores that are “unfair” in the sense that they do not necessarily capture the intent of the committee. On the other hand, the committee has provided explicit documentation of how the scoring was done so that grades can be recalculated using any other preferred system. In this sense, the scores are “fair” because, though necessarily subjective and vulnerable to the peculiarities of this particular set of weights and scoring rules, they are transparent and available for public scrutiny. The 2009 scores are not wholly consistent with the previous Report Card. In the 2006 National Report Card on the State of Emergency Medicine, weightings of categories were as follows: Access to emergency care: 40% Quality and patient safety: 25% Public health and injury prevention: 10% Medical liability environment: 25% In the 2009 version of the Report Card, the task force added disaster preparedness and thus redistributed weights for the other 4 categories. However, the 2009 scores could be recalculated to make the 2006 methodology, should a direct comparison be desired. Q2.d How does it compare with previous Report Cards? The National Report Card on the State of Emergency Medicine: 2006 was the first Report Card evaluating the state of emergency medicine in the United States. As mentioned above, the major categories were access to emergency care, quality and patient safety, public health and injury prevention, and medical liability environment. The 2009 Report Card included more than twice the number of indicators within each of the primary categories. The increased overall number of indicators resulted in a different weighting system within the primary categories. As the 2009 Report Card states, this limits the ability to make direct comparisons between the 2006 and 2009 versions on specific categories. However, the 2009 Report Card's grades are likely more representative of each state's actual environment because the increased number of indicators measures more critical areas within each of the 5 major categories. Q2.e What additional measures would you like incorporated into the 2012 Report Card? In 1980, Donabedian19Donabedian A. The Definition of Quality and Approaches to Its Assessment: Explorations in Quality Assessment and Monitoring, Vol 1. Health Administration Press, Ann Arbor, MI1980Google Scholar published his classic treatise on quality in health care that introduced the structure-process-outcome triad as a conceptualization of the components of quality care. Although we care most about outcomes, and particularly those outcomes that are improved as a result of the specific forms of structure and process, we often settle for measures of structure and process because outcome measures are hard to identify. However, because the goal of health care is to improve outcome, we should not be satisfied until we develop measures that directly assess outcome. The 2009 Report Card uses approximately 114 indicators grouped in 5 categories. Almost all are measures of structure. There are a handful of process measures and no outcome measures. Thus, although these indicators represent a thoughtful utilization of available objective data to assign a grade, they do not directly measure what kinds of outcomes are being achieved by our emergency care system or what types of processes are being used. In the future, it would be ideal if there were more process and outcome measures available for incorporation into the Report Card. Some process measures using tracer conditions are becoming available nationally.20Holmes R.H. Tracer methods to assess health.N Engl J Med. 1973; 288: 858PubMed Google Scholar These include time to antibiotics for pneumonia and time to catheterization laboratory for ST-elevation myocardial infarction. Unfortunately, the value of these measures as proxies for quality of care remains highly controversial. Other structural measures of quality include the electronic availability of patient medical records (structure) and the use of such records (process). Until such time when there is an overhaul of our health care system and the nationalization of patient records, it is unlikely that we will see readily available outcome measures. Q3.a Why publish a Report Card on the state of emergency care? Any Report Card is an objective, methodical tool used for evaluative purposes. The 2009 National Report Card on the State of Emergency Medicine merges many different metrics relevant to the delivery of emergency care. The Report Card also communicates to the public the growing concerns of those within the specialty. The Report Card is designed to bring attention to problems with emergency care in the United States by using objective data to draw comparisons across time and geographic boundaries. Its strength is that it concisely summarizes each state's emergency care in a manner than can be easily understood by policymakers. The Report Card will spark communication between different stakeholders (regulators, providers, and consumers, for example). It gives advocates for reform the evidence needed to support regulatory change, and it educates patients about the macroeconomic conditions affecting health care delivery. As suggested in its summary section, the Report Card is a “call to action” for the American public. It challenges many of the false assumptions that the American public may have about the emergency care environment, including timely access to specialty care, access to trauma centers, and governmental investments in emergency infrastructure. Our population often fails to recognize that as demand for emergency care continues to grow, our ability to provide it has, in some places, diminished. Q3.b What utility does it serve to policymakers, payers, providers, and the public? As America debates health reform, current data are of great value to those involved in the reform process. This Report Card summarizes to policymakers the ominous state of emergency care. For state-level policymakers, the Report Card provides a comparative evaluation of their own state's emergency care platform. It analyzes the state-level progress since 2006. At both the federal and state levels, an objective presentation of data, followed by a consensus expert-panel series of recommendations, is a powerful tool for reform. 21Fields W.W. Asplin B.R. Larkin G.L. et al.The Emergency Medical Treatment and Labor Act as a federal health care safety net program.Acad Emerg Med. 2001; 8: 1064-1069Crossref PubMed Scopus (57) Google Scholar, 22American College of Emergency PhysiciansEMTALA and on-call responsibility for emergency department patients.Ann Emerg Med. 2006; 48: 486-487Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 23Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemThe future of emergency care in the United States health system.Ann Emerg Med. 2006; 48: 115-120PubMed Google Scholar Third-party payers have major influence on the nation's health agenda. Both public (such as Medicare and Medicaid) and private (such as large commercial insurers) payers have a vested interest in the quality and efficiency of care delivered. Payers can motivate health care system changes by adjusting reimbursement. Emergency care providers probably recognize many concerns addressed within this Report Card. Providers, however, may not recognize how their practice environment compares across state lines. This Report Card is also a means for emergency providers to communicate their concerns in a unified voice, led by the expert panel of authors. This Report Card also has utility for providers outside the field of emergency medicine. It conveys how multiple parties, including primary care providers and subspecialist providers, have significant influence on the quality of care delivered in the ED. The Report Card summarizes for patients the dangers of increasing demand, a high-risk medicolegal environment, and a lack of disaster preparedness. This report also conveys to the public some of the many reasons behind ED boarding, extending wait times, and the lack of prompt specialty care in the ED.24Ragin D.F. Hwang U. Cydulka R.K. et al.Reasons for using the emergency department: results of the EMPATH Study Emergency Medicine Patients' Access to Healthcare (EMPATH) Study Investigators.Acad Emerg Med. 2005; 12: 1158-1166Crossref PubMed Google Scholar, 25Byrne M. Murphy A.W. Plunkett P.K. et al.Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics.Ann Emerg Med. 2003; 41: 309-318Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar Q3.c Substantial variation exists among states in each of the 5 categories that compose a grade. Discuss the factors within the Report Card that best explain this variation. Consider metrics at the patient, provider, and regulatory levels. Because most of the indicators in the Report Card evaluate the structure of emergency care delivery, differences among states' scores are primarily due to structural differences between states. That is not to say that states do not differ in process or outcome, just that these were not measured. The Report Card shows that urban and rural states have structural differences that would be expected, given the variablilty in geography and demographics. Urban states have higher numbers of providers but also have a greater demand for services. In turn, rural states may have a lower demand for emergency care, yet the availability of referral centers and providers is relatively less. The Report Card cites the data representing regional heterogeneity on page 14. There are noticeable exceptions to these urban-rural generalizations; North Dakota, Nebraska, and West Virginia, states with large rural populations, score highly in the Report Card. Not all differences among states are due to the structure of the health care system. Patient behavior also plays a role. Health economists have shown associations between socioeconomic status, education, and health behaviors.26Sturm R. The effects of obesity, smoking, and drinking on medical problems and costs.Health Aff (Millwood). 2002; 21: 245-253Crossref PubMed Scopus (677) Google Scholar, 27Ahluwalia I.B. Mack K.A. Murphy W. et al.State-specific prevalence of selected chronic disease-related characteristics—Behavioral Risk Factor Surveillance System, 2001.MMWR Surveill Summ. 2003; 52: 1-80PubMed Google Scholar, 28Anderson L.H. Martinson B.C. Crain A.L. et al.Health care charges associated with physical inactivity, overweight, and obesity.Prev Chronic Dis. 2005; 2 (Epub 2005 Sep 15): A09Google Scholar Patient behaviors, such as seatbelt use, firearms in the home, and cigarette consumption, vary substantially across the country and affect states' grades. Indicators such as emergency physicians per 100,000 (in the Access to Emergency Care category, with a weight of 3.57) reflect the willingness of health care personnel to live and work in an area. Physicians, nurses, and other providers will select a work environment according to factors such as proximity to where they grew up or where they trained, the demand for their services, reimbursement, quality of life, and the medicolegal environment. At the regulatory level, the laws and budgetary decisions of each state government directly affect the emergency care environment. Legislation about malpractice issues, emergency medical services (EMS) requirements, and public health infrastructure all affect a state's Report Card grade, as do the degree of fiscal support for disaster management, EMS, and public health programs. Q4.a The Report Card gives Massachusetts the highest overall state grade and Arkansas the lowest overall grade. Compare Massachusetts and Arkansas across the 5 categories used to assign a grade. One of the strengths of the Report Card is that it fosters direct comparison among states. It allows stakeholders within each state to evaluate their ability to provide emergency care relative to neighboring states or states with similar geography and demographics. The Report Card cites many problems with the emergency care in Arkansas, including an insufficient supply of physicians, a poor public health infrastructure, and limitations in the fields of traumatic illness and disaster preparedness. The per-capita access to both emergency physicians and certain subspecialists is among the worst in the nation. More than 22% of adults in Arkansas lack health insurance. Arkansas also has the third lowest seatbelt use rate in the country. Arkansas has neither a syndromic surveillance syndrome nor a statewide medical communications system. Contrast this with Massachusetts, which ranks at or near the top in several metrics. Successes include injury prevention measures, low rates of obesity, and mature quality improvement systems. Massachusetts has advanced state-level coordinated care of individuals with traumatic illness and ST-elevation mycoardial infarction. The state has also adopted progressive reforms that have substantially reduced the number of uninsured. Massachusetts outperformed Arkansas in all categories except “Medical Liability Environment.” In the category of “Access to Emergency Care,” the Report Card grades Arkansas a D– and Massachusetts a B. Massachusetts has 3 times the per-capita number of board-certified emergency physicians relative to Arkansas. Massachusetts also has between 1.5 and 3 times the number of per-capita subspecialists in the specialties analyzed in the Report Card. To Arkansas' credit, the state has more per-capita EDs and inpatient beds than Massachusetts, which do compose a significant portion of this category's grade. As an example, the 3 indicators listed in Table 1 show that Massachusetts has more emergency physicians per capita, and the majority of the population lives in close proximity to a trauma center. On the other hand, only 6% of Arkansas' population lives within 60 minutes of a trauma center, likely because of the state's rural population base. Although Arkansas has more EDs per capita, the low weighting of this indicator has little effect on the overall state grade.Table 1Comparison of sample quality indicators for access to emergency care for Arkansas and Massachusetts.IndicatorsArkansasMassachusettsWeightEmergency physicians per 100,000 population6.916.93.57EDs per 1,000,000 population28.89.83% of population within 60 minutes of Level I or II trauma center6.196.85 Open table in a new tab In the category of “Medical Liability Environment,” Arkansas received a grade of C+, whereas Massachusetts received a grade of D. Insurance premiums, the number of insurers, and the average malpractice payment are some of the indicators in which Arkansas outperformed Massachusetts, leading to its better grade. Under “Quality and Patient Safety Environment,” Arkansas received a grade of F, whereas Massachusetts received a grade of A. This, too, will be discussed below, but the number of emergency medicine residents, an investment in health information technology, and reporting requirements are a few leading metrics that separate these 2 states. The final categories of “Public Health and Injury Prevention” and “Disaster Preparedness” show additional clear differences between Arkansas and Massachusetts. Arkansas received an F in both categories, whereas Massachusetts received grades of A and B, respectively. Relative to Massachusetts, Arkansas has 3 times the number of per-capita traffic fatalities, lacks any robust gun-purchasing legislation, and does not have a coordinated state emergency communications and surveillance system. Q4.b Which categories most clearly show why Massachusetts outperforms Arkansas? In both the categories of “Quality and Patient Safety Environment” and “Public Health and Injury Prevention,” Massachusetts scores a grade of A, whereas Arkansas scores a grade of F. In the categories of “Access to Emergency Care” and “Disaster Preparedness,” Massachusetts receives a grade of B in both categories, whereas Arkansas receives a grade of D– and F, respectively. Among these categories, there are several indicators that fuel Massachusetts' superior grade. Several are mentioned above. Specific metrics include the per-capita number of board-certified emergency physicians and subspecialists, the per-capita number of emergency medicine residents, per-capita traffic fatalities, statewide surveillance and reporting systems, percutaneous coronary intervention networks, motorcycle helmet use legislation, and unintentional burn and firearm-related fatalities. Q4.c Are there any metrics in which Arkansas outperforms Massachusetts? There are several indicators for which Arkansas outperformed Massachusetts. Some noticeable examples include the per-capita number of chest pain centers and pediatric specialty centers; total per-capita EDs; per-capita staffed inpatient, ICU, and psychiatric beds; hospital occupancy rates; malpractice payments; malpractice insurers; insurance premiums; hospital-based infection reporting requirements; sentinel event reviews; use of tobacco settlement funds; and binge alcohol use. It was interesting that the number of lawyers per capita, although reported, had a weighting of 0, meaning that it does not contribute to the “medical liability environment” grade. Of note, the per-capita number of lawyers in Massachusetts is twice that of Arkansas. In addition to the individual indicators noted above, Arkansas received a higher overall grade in the category of “medical liability environment.” The state summary for Massachusetts notes a difficult medical liability arena, with an average malpractice award “among the highest in the nation at $437,000 compared to the $285,218 national average.” Furthermore, Massachusetts has a low number of insurers providing malpractice coverage. Arkansas, meanwhile, has passed medical liability reform legislation and has some of the lowest medical liability insurance premiums in the country. Q4.d How should one interpret this head-to-head comparison, and what caveats exist for such comparisons? Although the 2 states have indisputable differences in their scores it must be remembered that: a) the measures focus on structural issues and do not reflect process or outcome of care; b) the weightings are based on an expert panel's beliefs, and other weights could enlarge or diminish the between-state difference; and c) some of the indicators have more to do with the health status of the state's constituents than the quality of its emergency health care delivery system. Q5.a The panel makes 8 core recommendations according to the results of the Report Card. How might a policymaker interpret these recommendations? The 8 core recommendations are stated on page 11 of the Report Card and are similar to those made in 2006 and those made in the Institute of Medicine's report on hospital-based emergency care.1Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemHospital-Based Emergency Care: At the Breaking Point. National Academies Press, Washington, DC2006Google Scholar The specific recommendations range from general principles such as “alleviate boarding and crowding in EDs” to specific legislative recommendations such as “pass the Access to Emergency Medical Services Act.” It is hoped that policymakers will use the former as guidance when defining policy. Recommendations of the latter type are designed to provide specific direction about urgent legislative matters. Data for policymakers should be clear, concise, and accessible.29Colby D.C. Quinn B.C. Williams C.H. et al.Research glut and information famine: making research evidence more useful for policymakers.Health Aff (Millwood). 2008; 27: 1177-1182Crossref PubMed Scopus (26) Google Scholar A policymaker would consider these recommendations within the larger context of the goals of national health reform.30Pauly M.V. Blending better ingredients for health reform.Health Aff (Millwood). 2008; 27: w482-w491Crossref PubMed Scopus (8) Google Scholar, 31Baker C.D. Caplan A. Davis K. et al.Health of the nation—coverage for all Americans.N Engl J Med. 2008; 359: 777-780Crossref PubMed Scopus (9) Google Scholar In the current fiscal climate, policymakers will no doubt approach these recommendations with one question in mind: what will they cost? Every organization believes that its issues are of primary importance. Legislators must decide which items on each group's wish list will be most beneficial to the public. A benefit of the Report Card strategy is that it may be compelling at the state level, particularly for those states with a poor grade. A downside is that the strategy of giving the best states an A regardless of their raw score may provide an inappropriate sense of complacency at the federal level and in states that score well. Q5.b What are the barriers at the state and federal level to implementing such reforms? As noted above, fiscal constraints are likely to limit federal reform efforts in the short term. Health reform will likely take a backseat early in the Obama administration to the politically charged demands of reversing the financial, credit, and real estate crises plaguing our economy. On a federal level, in the first years of the new administration those projects that are (a) viewed as infrastructure repair, (b) likely to generate new jobs, and (c) likely to provide economic value that extends beyond the project's intrinsic purpose are most likely to be funded. In our opinion, none of the 8 recommendations clearly meet test criteria, and it may be some time before these recommendations gain purchase. Circumstances are likely to vary greatly among states, depending on their unique fiscal circumstances and legislative climate. It is likely that, in the short term, the Report Card will have its greatest effect at this level. Regardless of the fiscal climate, some recommendations will meet resistance from other interest groups, most obviously the trial lawyers who will do their best to thwart malpractice tort reform. It remains to be seen how Washington and the individual states will handle such conflicts. Of note, some southern states, including Texas, Georgia, and South Carolina, have already have enacted malpractice reform, suggesting that further reform may be tenable. The National Report Card on the State of Emergency Medicine: Evaluating the Emergency Care Environment State by State 2009 EditionAnnals of Emergency MedicineVol. 53Issue 1Preview Full-Text PDF
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