It would seem to be conventional wisdom that providing high-quality emergency room care is a critical part of protecting the overall health of the public—particularly when treating people with chronic illnesses with acute exacerbations that may require trauma care. For this reason, carefully evaluating the emergency procedures practiced by the nation’s hospitals should be an important part of comparative effectiveness research (CER) and patient-centered outcomes (PCO) research, argue Zack Meisel, MD, PhD, Brendan Carr, MD, MS, and Patrick Conway, MD, MS.
“As an emergency physician, I became aware that the Institute of Medicine (IOM), the Patient-Centered Outcomes Research Institute (PCORI) and other organizations were not explicitly including time-sensitive, episodic medical care in their approach to comparative effectiveness research. Not enough thought was being given to conditions such as stroke, trauma care, and acute exacerbations of chronic conditions,” explains Meisel, a 2008-2011 Robert Wood Johnson Foundation (RWJF) Clinical Scholar and assistant professor in the department of emergency medicine at the Perelman School of Medicine at the University of Pennsylvania.
“When you conduct CE research through a condition-specific lens, you can lose the opportunity to evaluate emergency medicine from a policy standpoint or to assess which delivery systems improve this type of care,” adds Conway, an RWJF Clinical Scholar 2005-2007, who is also chief medical officer at the Centers for Medicare & Medicaid Services (CMS).
“It’s not that there’s a conscious effort to exclude emergency care, it is the way problems are framed and questions are asked in CER and PCO research,” Meisel adds. “There is a tendency to look at patient disease management over the lifespan and emergency care is not seen as a part of that.” But of course, crisis care is very important to the overall health of patients.
“For many patients, the emergency room is part of the health care safety net. It’s a place where a lot of the things that affect health take place, such as contact with a social worker or receiving prescriptions for medication,” Meisel says.
In addition, the team noted in their paper, “From Comparative Effectiveness Research to Patient-Centered Outcomes Research: Integrating Emergency Care Goals, Methods, and Priorities,” published in the May 2012 issue of the Annals of Emergency Medicine, “that 55 percent of hospital admissions (excluding those for pregnancy and childbirth) begin in the emergency room (ER) and that acute conditions, such as diabetes, obstructive lung disease, hypertension, asthma and others are the primary causes of more than 2.5 million adult ER visits per year.”
In an attempt to eliminate the disconnect between emergency care and CE and PCO research, Meisel, Conway and Carr have designed a conceptual framework, presented in their paper, to “give people who conduct CE and PCO research the language and context to include emergency care in their work,” Meisel says.
A 2006-2008 RWJF Clinical Scholar and assistant professor of emergency medicine at the Perelman School of Medicine at the University of Pennsylvania, Carr is also an expert researcher in the field of emergency system design. His previous work on ER access has focused on a broad range of topics, including a 2010 study, “Variation in Critical Care Beds Per Capita in the United States: Implications for Pandemic and Disaster Planning,” published in the Journal of the American Medical Association. It found that the nation’s emergency rooms were ill-prepared to handle a pandemic or disaster.
Incorporating Emergency Care
Using the four categories of CER established by the Federal Coordinating Council for Comparative Effectiveness Research at the U.S. Department of Health and Human Services, the definition of patient-centered care used by PCORI, and a list of priority medical conditions supplied by the Institute of Medicine, the team’s framework identifies key patient populations and illnesses to be analyzed in “real world” settings such as the ER, emergency medical services pre-hospital care, community-based ambulatory clinics and urgent care.
Drawing on Carr and Meisel’s experiences as emergency physicians, and Conway’s policy expertise and work as a pediatrician in hospital settings, the team identified several methods for evaluating care and measuring outcomes. The goal of the model is to allow researchers to translate and disseminate their findings among patients, providers, policy-makers, insurers and other payers.
“A recent experience we had here at CMS illustrates the need and potential uses for our conceptual framework,” Conway explains. “Representatives of the American Burn Association came into our office to talk about whether to regionalize burn care. They are trying to decide how best to distribute regional burn [trauma] centers around the country and determine how we might deliver better burn care. The problem is that there’s limited CER or PCO data on regionalization and optimal delivery of burn care at this point. Working with our framework, researchers could produce information to help answer these types of questions.”
Drawing on the Scholar Experience
“When I began my Clinical Scholar term, I was new to comparative effective research,” Meisel says. “I learned to do this work because of the experience in the program.”“My Clinical Scholar training was also the foundation I use for the work I do every day, especially the lessons learned about quality measurement, leadership and policy,” Conway adds.
Going forward, “we want to help people see that emergency medicine is the leading edge of the health care system in many ways, because it is the most common entry point for most patients to the hospital,” Conway says. “It is an ideal place to study the health system and identify opportunities for improvement and change.”
Clinical Scholars program
The Robert Wood Johnson Foundation Clinical Scholars program advances the development of physicians who are leaders in transforming health care through positions in academic medicine, public health, and other roles. The program trains clinicians in the program development and research methods that will enable them to find solutions to the many challenges posed by the health care system, community health and health services research.
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