Emergency Medicine

AEM Early Access16: Patients' Perceptions of Shared Decision Making in the ED

Welcome to the sixteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

AEM Podcasts logo[3].png

DISCUSSING (OPEN ACCESS THROUGH JULY 31, 2018; CLICK ON TITLE TO ACCESS)

A Qualitative Analysis of Patients’ Perceptions of Shared Decision Making in the Emergency Department: “Let Me Know I Have a Choice”
Elizabeth M. Schoenfeld MD, MS  Sarah L. Goff MD  Gwendolyn Downs DO  Robert J. Wenger DO Peter K. Lindenauer MD, MSc  Kathleen M. Mazor EdD

LISTEN NOW: INTERVIEW WITH LEAD AUTHOR DR. SCHOENFELD

Elizabeth formal picture.png

Elizabeth M. Schoenfeld MD, MS

Assistant Professor, Department of Emergency Medicine

Institute for Healthcare Delivery and Population Science

UMASS Medical School - Baystate

Adjunct Faculty, Tufts School of Medicine

ABSTRACT:

Background and Objectives
Despite increasing attention to the use of shared decision making (SDM) in the emergency department (ED), little is known about ED patients’ perspectives regarding this practice. We sought to explore the use of SDM from the perspectives of ED patients, focusing on what affects patients’ desired level of involvement and what barriers and facilitators patients find most relevant to their experience.

Methods
We conducted semistructured interviews with a purposive sample of ED patients or their proxies at two sites. An interview guide was developed from existing literature and expert consensus and based on a framework underscoring the importance of both knowledge and power. Interviews were recorded, transcribed, and analyzed in an iterative process by a three‐person coding team. Emergent themes were identified, discussed, and organized.

Results
Twenty‐nine patients and proxies participated. The mean age of participants was 56 years (range, 20 to 89 years), and 13 were female. Participants were diverse in regard to race/ethnicity, education, number of previous ED visits, and presence of chronic conditions. All participants wanted some degree of involvement in decision making. Participants who made statements suggesting high self‐efficacy and those who expressed mistrust of the health care system or previous negative experiences wanted a greater degree of involvement. Facilitators to involvement included familiarity with the decision at hand, physicians’ good communication skills, and clearly delineated options. Some participants felt that their own relative lack of knowledge, compared to that of the physicians, made their involvement inappropriate or unwanted. Many participants had no expectation for SDM and although they did want involvement when asked explicitly, they were otherwise likely to defer to physicians without discussion. Many did not recognize opportunities for SDM in their clinical care.

Conclusions
This exploration of ED patients’ perceptions of SDM suggests that most patients want some degree of involvement in medical decision making but more proactive engagement of patients by clinicians is often needed. Further research should examine these issues in a larger and more representative population.

ADDITIONAL READING:

Probst MA, Kanzaria HK, Schoenfeld EM, Menchine MD, Breslin M, Walsh C, et al. Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians. Annals of Emergency Medicine. 2017 Nov;70(5):688–95. 

Schoenfeld EM, Goff SL, Elia TR, Khordipour ER, Poronsky KE, Nault KA, et al. A Qualitative Analysis of Attending Physicians' Use of Shared Decision-Making: Implications for Resident Education. Journal of Graduate Medical Education. 2018 Feb;10(1):43–50. 

AEM Early Access 07: Patterns and Costs of Patients Visiting Multiple EDs

Welcome to the seventh episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

Discussing: (click on title for full text, open access through November 30, 2017)

Patients Visiting Multiple Emergency Departments: Patterns, Costs and Risk Factors

Todd W. Lyons MD, MPH, Karen L. Olson PhD,Nathan P. Palmer PhD, Reed Horwitz, Kenneth D. Mandl MD, MPH, Andrew M. Fine MD, MPH

LISTEN NOW: INTERVIEW WITH LEAD AUTHOR DR. TODD LYONS, MD MPH

Dr Todd Lyons

Dr. Todd Lyons, MD MPH

Clinical Instructor, Harvard Medical School

Staff Physician, Boston Children's Hospital

Article Summary

Objective: The authors of this study investigated the prevalence and impact of ED care fragmentation by characterizing the population of patients seeking care at multiple EDs and quantifying costs associated with this patient population.

 

Methods: This is a retrospective cohort study of insured patients who had one or more ED visit between 2010 and 2016. Outcomes investigated included number of EDs visited by each patient, the costs associated with this subset of patients, and factors associated with visiting multiple EDs.

 

Results: The study included 53,015,427 patients belonging to a single for-profit payer. Of this group, 8,651,716 patients had at least 1 ED visit and accounted for 16,390,676 ED visits resulting in  $26,102,831,740 in ED costs.

  • 20.5% of patients visited more than one ED but accounted for 41.4% of visits and 39.2% of costs

  • A small proportion (0.4%) of patients visited 5 or more EDs but accounted for 2.8% of ED visits and costs

  • Factors most strongly associated with visiting multiple EDs included age, living in the South, total years of enrollment and higher visit complexity

  • Diagnoses most strongly associated with visiting multiple EDs included alcohol and drug diagnoses and mental health disorders

 

Conclusion: A minority of patients seek care at multiple EDs but account for a significant cost burden. Characterization of this population suggests they represent higher complexity visits and are more likely to suffer from comorbid substance abuse and mental health conditions. The authors recommend further work to evaluate the impact of ED care fragmentation of care utilization and outcomes and recommend improving access to patient records to mitigate its effects.

SUGGESTIONS FOR FURTHER READING:

1.  Bourgeois FC, Olson KL, Mandl KD. Patients treated at multiple acute health care facilities: Quantifying information fragmentation. Arch Intern Med. 2010;170(22):1989-1995. 


2.  Cook LJ, Knight S, Junkins EP, Mann NC, Dean JM, Olson LM. Repeat Patients to the Emergency Department in a Statewide Database. Acad Emerg Med. 2004;11(3):256-263. 


3.  Fertel, Baruch S., Hart, Kimberly W., Lindsell, Christopher J., Ryan, Richard J., Lyons MS. Patients Who Use Multiple EDs: Quantifying the Degree of Overlap Between ED Populations. West J Emerg Med. 2015;49(2):229. 

AEM Early Access 06: Gender and Racial Disparities Among Academic Emergency Medicine Physicians

Welcome to the sixth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

LISTEN NOW: Author INTERVIEW WITH DR. TRACY MADSEN

headshot (1) (3).jpg

Dr. Tracy Madsen

Assistant Professor, Division of Sex and Gender in Emergency Medicine (SGEM)

Department of Emergency Medicine

Alpert Medical School, Brown University

Full text of this month's article (open access through November 1, 2017): Click below

Tracy E. Madsen, et al., “Current Status of Gender and Racial/Ethnic Disparities Among Academic Emergency Medicine Physicians,” A Joint 2015 Report by Academy for Women in Academic Emergency Medicine (AWAEM), Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) and Academy of Administrators in Academic Emergency Medicine (AAAEM).

ARTICLE SUMMARY:

Objective: A 2010 survey identified disparities in salaries by gender and underrepresented minorities.  With an increase in the EM workforce since, the authors aimed to 1) describe the current status of academic EM workforce by gender, race and rank, and 2) evaluate if disparities still exist in salary or rank by gender.

Methods: Information on demographics, rank, clinical commitment, and base and total annual salary for full-time faculty members in U.S. academic EDs was collected in 2015 by the Academy of Administrators in Academic Emergency Medicine (AAAEM) Salary Survey.  Multiple linear regression was used to compare salary by gender while controlling for confounders.

Results:

  • Response rate was 47% for 1371 full-time faculty

  • 33% were women

  • 78% White, 4% Black, 5% Asian, 3% Asian Indian, 4% other, and 7% unknown race

  • White vs nonwhite race:

    • 62% vs 69% instructor/assistant

    • 23% vs 20% associate

    • 15% vs 10% full professors

  • Women vs men (p<0.05):

    • 74% vs 59% instructor/assistant

    • 19% vs 24% associate

    • 7% vs 17% full professors

    • 37% vs 31% fellowship trained

    • 59% vs 64% Core Faculty

    • 47% vs 57% had administrative roles

    • 1069 vs 1051 clinical hours worked

  • 15% of 113 Chair/Vice-Chair positions were women, 18% were nonwhite race

  • Mean salary: $278,631

    • Mean salary of women was $19,418 less (SD +/- $3,736, p<0.001) even after adjusting for race, region, rank, years of experience, clinical hours, core faculty status, administrative roles, board certification, and fellowship training

Conclusions: In 2015, disparities in salary and rank persist among full-time U.S. academic EM faculty, even after controlling for key factors that have been speculated to contribute to salary differences, such as rank, clinical hours, and training.  There were also gender and underrepresented minority disparities in rank and leadership positions.  Future efforts should focus on evaluating salary data by race and developing system-wide practices to eliminate disparities.

Suggestions for further reading:

Jena AB, Olenski AR, Blumenthal DM, A S, P U, R J. Sex Differences in Physician Salary in US Public Medical Schools. JAMA Intern Med. 2016;176(9):1294. 

Heron SL, Lovell EO, Wang E, Bowman SH. Promoting Diversity in Emergency Medicine: Summary Recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup. Acad Emerg Med. 2009;16(5):450-453. 

Choo EK, Kass D, Westergaard M, et al. The Development of Best Practice Recommendations to Support the Hiring, Recruitment and Advancement of Women Physicians in Emergency Medicine. Pines JM, ed. Acad Emerg Med. June 2016. 

Faculty Editor/Reviewer: Dr. Gita Pensa 

Podcast credits: Intro/exit music by Scott Holmes and freemusicarchive.org. Also featuring "Money", Pink Floyd, from The Dark Side of the Moon.