As the national physician shortage worsens, areas of the country with aging OB-GYN clinicians and high OB-GYN workloads are expected to face a high risk for physician shortfalls.
With a severe shortage of OB-GYN clinicians forecasted, some metropolitan areas are more prone to crisis-level conditions than others, according to research released today.
The stakes for women's health are high, according to Amit Phull, MD, vice president of strategy and Insights at San Francisco-based Doximity, which conducted the research.
"We're facing a national physician shortage in the years to come. OB-GYNs are one of the top specialties at risk and are central to women's healthcare in the U.S. The emergence of a significant shortage in this specialty could be terribly problematic from a women's health standpoint," Phull said in a prepared statement.
The American Congress of Obstetricians and Gynecologists (ACOG) estimates there will be a shortage of up to 8,800 OB-GYNs by 2020, with the shortfall approaching 22,000 by 2050.
The Doximity study includes data from the Centers for Medicare & Medicaid Services, board certifications, and self-reported information from about 43,000 OB-GYN clinicians. The research, 2018 OB-GYN Workforce Study, focused on the largest 50 U.S. metropolitan statistical areas by population.
One of the key features of the Doximity study is a risk index designed to identify which cities could feel the brunt of the OB-GYN shortage first. The risk index has two factors: the average age of the local OB-GYN workforce and the workload they carry based on births per OB-GYN per year.
"In the metropolitan areas with older OB-GYNs and higher workloads, we expect that they have a greater risk of shortages. In the metropolitan areas with younger OB-GYNs and lower workloads, we expect that they have a lower risk of shortages," the Doximity researchers wrote.
The Top 5 cities considered at high risk for an OB-GYN shortage are Las Vegas; Los Angeles; Miami; Orlando; and Riverside, California.
The Top 5 cities considered at low-risk for a shortage are Ann Arbor, Michigan; Birmingham; Portland, Oregon; San Jose; and Baltimore.
The Doximity study features several other key findings:
In the study's 50 metropolitan areas, the number of OB-GYNs was compared to the number of annual births. St. Louis posted the highest workload, with 247 births per OB-GYN. Ann Arbor had the lowest workload at 32 births per OB-GYN. With service-volume capacity, low-workload areas should be resistant to physician shortages.
Retirements are a key driver of the OB-GYN shortage. The average age of OB-GYNs was 51, with Pittsburg posting the oldest age at 52.32 and Houston posting the youngest at 48.38. The median retirement age for OB-GYNs is 64, according to ACOG.
More than a third of OB-GYNs were 55 or older. In 32 out of the 50 metropolitan areas in the study, at least one third of the OB-GYNs were 55 or older.
Only 16 percent of OB-GYNs were 40 or younger. In 12 of the metropolitan areas, less than 15% of OB-GYNs were 40 or younger.
Metropolitan areas with large OB-GYN workloads also tended to have the highest number of women who were uninsured or covered by Medicaid. With Medicaid reimbursement trailing private insurance, these areas have downward pressure on OB-GYN compensation.
Successful concierge medicine practices have a patient-centered philosophy, small scale, financial strength, strong care coordination, and focus on prevention, a concierge physician and author says.
Embracing patient-centered care is an essential ingredient for success at concierge medicine practices.
"We are focused on doing everything we can do to exceed the expectations of the patient," says David Winter, MD, a concierge medicine physician in Dallas and chairman and president of HealthTexas Provider Network, a physician group affiliated with Baylor Scott & White Health.
Concierge medicine is based on a membership model, where the concierge physician receives a monthly or annual fee to subsidize amenities not offered in most primary care offices. Those amenities include 24/7 access to a physician, same-day appointments, and the ability to have lengthy office visits if necessary.
There are five best practices to operate a successful concierge medicine practice, says Winter, who recently published a book, ServiceExtraordinaire: Unlocking the Value of Concierge Medicine.
1. Primacy of Patient Experience
Well-run concierge medicine practices provide an excellent patient experience, he says.
"You have prompt access, 24/7; phone, text, or email communication at the patient's choice; and our office visits are unrushed and lengthier than standard clinics."
Concierge medicine is the antithesis of the past's practice of medicine, Winter says. "In many of the old practices, it was built for the physician—the schedule was set for the physician, the parking places were closer for the physician. We've switched all of that. Our patients get valet parking, and we pay."
At Winter's practice, BSW Signature Medicine - Tom Landry, efforts to enhance the patient experience start the moment a patient comes through the door, he says.
"We'll serve them water, coffee, or soft drinks. We'll update their records. They don't have any idle time. We don't want them to wait. In fact, we don't call our entry room a waiting room, we call it a greeting room."
2. Less is More in Scale
The optimal scale for a concierge practice is a single physician, Winter says. "The ideal way to run a concierge practice is with a physician who has been in practice [for a] while and has a relationship with patients."
Establishing relationships with patients enhances care, he says. "It's about a one-on-one relationship between a patient and a physician—a trusting relationship. That augments the care of the patient."
3. Retainer Fee Financing Model
Monthly and annual patient retainer fees help finance concierge practices. There are two approaches, Winter says.
"You can charge a retainer fee and bill people for billable events, which is the way we do it. If you come in with bronchitis, we will send a bill to the insurance company or Medicare. The other way is to have a higher retainer fee, with no billing for anything."
For Winter's practice in the Dallas market, the blended approach made more sense. "People have the insurance anyway. Patients need it in any concierge practice for specialty care and hospitalization. They had the insurance anyway, so we felt that was the easier way to go."
In North Texas, retainer fees range from $1,800 to $18,000. Winter says his practice's retainer fee is at the low end of that scale.
The retainer fee financial model helps concierge practices generate more income than many standard primary care practices. "If the patients are paying annual retainer fees, then the physician does not have to see 20 or 25 patients per day to pay overhead and generate income," Winter says.
Time is a precious commodity at a physician practice, he says.
"I was in practice for 20 years, had a very busy practice, and I went from one patient to the next. I would focus very intently on my patients; but once a patient was out of the exam room, you forgot about them and were on to the next one. With concierge medicine, you can think about patients, do research, and call them back to see how they are doing."
4. Care quarterbacks
Most concierge practices offer primary care, and the best ones prioritize care coordination, he says.
"They are the quarterback of a patient's medical team. They will get the specialists they need to take care of the patient, but the care all runs through one physician," Winter says. "How you coordinate care is a key factor in concierge medicine—you want to make sure you are doing all you can do for the patient. You use specialists as necessary to augment the care."
5. Promoting preventive care
The best concierge practices also focus on preventive care, he says.
"Every afternoon when I am working in my administrative role, my nurse goes through our patients to see who is behind on colonoscopies, mammograms, and vaccinations," he says. "My nurse calls patients to get them into the office, so our quality scores are very high."
In quality scores, Winter's concierge practice consistently ranks in the top of Baylor Scott & White Health's 340 primary care practices, he says.
The luxury of time is critical in preventive care, Winter says. "When we were working together in my standard practice, we didn't have the time to do preventative services work. … When you do all of these things properly, you can save lives. People who get colonoscopies get less cancer."
Winter is trying to bring elements of concierge medicine to the physician practices in the HealthTexas Provider Network. "We're working on access, consumerism, same-day scheduling, and online scheduling—all things that I have been doing for a long time in concierge medicine."
For surgical patients who received nutritional intervention in the hospital, the 30-day readmissions rate was cut nearly in half.
Compared to hospitalized medical patients, surgical patients benefit more from malnutrition screening and intervention, researchers say.
The study, which collected data from 1,269 patients in a nutrition-focused quality improvement program and 1,319 control patients, found the 30‐day readmission rate for surgical patients dropped nearly in half, falling from 19.6% to 10.4%.
"Malnourished hospitalized surgical and medical patients experienced improved readmission rates and length of stay. However, surgical patients saw a significantly greater reduction in the readmission rate," the researchers wrote.
For surgical patients, the readmissions rate was 22.3% for the control group and 17.7% for the quality improvement program patients.
Length of stay reductions were also greater for surgical patients, with LOS for surgical patients dropping 2.7 days, from 9.3 days to 6.6 days. Medical patients experienced a 2.1-day LOS decline, from 7.1 days to 5.0 days.
As many as 50% of patients are malnourished or at risk of malnutrition when they are admitted to a hospital. Surgical patients face high risk, the researchers wrote. "Surgical patients in particular are vulnerable to a decline in nutrition status during hospitalization."
The researchers say surgical patients face four primary nutrition-related risks during their hospitalization:
Delayed wound healing
Postoperative complications such as surgical site infections
Longer LOS
Higher readmission rates
Hospitals and surgeons should intervene when a surgical patient is malnourished, the researchers wrote. "The avoidance of nutrition therapy bears the risk of underfeeding, which will in turn result in significant postoperative complications."
For this study, which was published in the Journal of Parenteral and Enteral Nutrition and funded by Lake Bluff, Illinois-based Abbott, the nutrition-focused quality improvement program had four primary elements:
Malnutrition screening
For malnourished patients or patients at risk of being malnourished, oral nutrition supplements were provided in less than 48 hours
Nutrition information was provided for both the patient and caregivers
The electronic medical record triggered dietitian consultations and specified oral nutrition supplements depending on a patient's condition
With health outcomes and cost savings on the line, the researchers urge surgeons to embrace nutritional interventions for their patients.
"We particularly call surgeons to action—to raise awareness of the importance of nutrition on surgical outcomes, to partner with hospital administration to obtain appropriate support for nutrition care processes, and to expand nutrition education and training in residency and continuing medical education programs."
Training is a weak link in efforts to address malnourishment among medical and surgical patients, the researchers wrote.
"In a recent survey, 72% of managers of U.S. medical residency programs stated that an advanced course in nutrition should be required of residents. However, only a quarter of residency programs include a formal course in nutrition, and half of those are taught to family practitioners, not surgeons."
With an increasing volume of mental health visits at emergency rooms, telemedicine has the potential to improve clinical care and ER operations.
Researchers are calling for the expansion of telepsychiatry services in the country's emergency departments (EDs).
In an article published this month in the American Journal of Emergency Medicine, the researchers found multiple benefits from ED telepsychiatry.
"The development of novel patient platforms such as telemedicine may offer an innovative approach to mental health care in the ED that may optimize and improve patient outcomes while also helping to reduce challenges such as ED overcrowding and limited specialist availability," the researchers wrote.
Earlier research has shown a pressing need to boost mental health services in emergency rooms. One study showed that 1 out of 8 ED visits involves mental health as the chief complaint.
There are two main clinical benefits from enhancing ED mental health services, the corresponding author of the American Journal of Emergency Medicine research, Bernard Chang, MD, PhD, told HealthLeaders this week:
The ED allows clinicians to intervene in the ultra-acute setting, when a psychiatric event has occurred or is at greatest risk of occurring
The ED can help offer seamless integration with behavioral health specialists that patients may otherwise have challenges coordinating on their own
Anxiety and depression appear to be particularly well-suited for ED telepsychiatry, Chang says. "Many of the assessments and treatments can be done remotely."
He says telepsychiatry can spare anxiety and depression patients the stress associated with busy EDs. "The acute care environment may sometime exacerbate psych complaints. So, the less time patients can be in that chaotic environment, the better, particularly those with anxiety or depression."
Several healthcare organizations have published positive results from using a telemedicine platform for psychiatry, Chang and his coauthor wrote. In addition to treating depression and anxiety, those programs reported success in cognitive behavior therapy as well as supportive therapy for PTSD patients.
Telemedicine programs such as telestroke care have been adopted at many EDs, but ED telepsychiatry is relatively rare. Financial factors are among the obstacles, the American Journal of Emergency Medicine researchers wrote.
"In a survey of several ED telepsychiatry programs, researchers found that key challenges included financial sustainability of such programs ranging from initial upfront startup costs to ongoing carrying costs associated with maintaining such a program."
Despite the challenges, the potential benefits of ED telepsychiatry are significant, the researchers wrote.
"ED overcrowding has been associated with multiple negative outcomes from patient satisfaction, medical errors, and patient perceptions of clinician communication. ED telepsychiatry may help offset patient burden in the ED and improve overall length of stay and patient satisfaction."
Researchers say reforming state and local rules for advanced practice providers can boost productivity, lower cost of care, and improve access to healthcare services.
Expanding the scope of practice for physician assistants and advanced practice registered nurses is a golden opportunity for U.S. healthcare, Brookings Institution researchers say.
Reducing restrictions on scope of practice (SOP) for physician assistants (PAs) and advanced practice registered nurses (APRNs) generates significant benefits without compromising quality of care, the researchers say.
"To the extent that APRNs and PAs provide healthcare that is equal in quality at a lower cost—as the existing research demonstrates—removing restrictions on their practice can help alleviate shortages and improve efficiency," they wrote in their report, "Removing Anticompetitive Barriers for Advanced Practice Registered Nurses and Physician Assistants."
The study was published this month.
SOPs, which are mainly generated in state legislatures, feature limitations on the tasks and autonomy of advanced practice providers such as APRNs and PAs. Physicians generally are not subject to SOP restrictions.
The researchers say SOPs have three primary negative impacts:
Depressed productivity: Finetuning the staffing mix of clinical care teams increases efficiency, but it is often blocked by anticompetitive policy barriers in SOPs
Cost of care: Compared to physicians, APRNs and PAs are lower-cost sources of labor who can provide equivalent quality of care
Access: SOP restrictions on advanced practice providers are a missed opportunity to ease the country's physician shortage
Physicians and their associations have lobbied against SOP reform based on quality of care concerns. "Opponents contend that quality of care may suffer under the direction of a non-physician practitioner, citing the shorter length of training and clinical experience required," the researchers wrote.
There is no evidence to support the quality of care claim, the researchers wrote. "The academic literature finds no evidence of harm to patients associated with less-restrictive SOP laws."
If there is no quality concern, then there is no justification for restrictive SOP laws, they wrote.
"When no harm is present, the restrictions serve only to generate artificial barriers to care that ultimately provide physicians with protection from competition, prevent the attainment of system-wide efficiencies, and constrain overall provider capacity."
There are three main SOP rules for PAs:
SOP determination: Entities responsible for setting SOP for PAs varies by state, with rules set at practices, state medical boards, and state legislatures
Supervision: Oversight requirements for PAs include work plans that specify allowed procedures as well as guidelines for physician consultation and monitoring
Prescription authority: Medication rules include the exclusion of some drugs from a PA's allowable prescriptions
SOP rules for APRNs are set in state legislatures, and there are two main rules:
Practice authority: The practice independence of APRNs ranges from no restrictions, to collaborative or consultative arrangements, to supervisory relationships
Prescription authority: State laws grant prescription authority, set the schedule or types of medications allowed, and determine the level of physician supervision
Policy proposals
The Brookings researchers make six primary recommendations to ease SOP restrictions:
States should allow APRNs and PAs to practice in accordance with their education, training, and experience
When a physician and an advanced practice provider are both qualified to perform a service, the clinician with the comparative advantage should provide the service to maximize efficiency
For APRNs, end supervisory or delegative practice arrangements, stop formal collaborative practice agreements, allow prescription of medications, and scrap APRN-to-physician ratio rules
Set the level of interaction between physicians and PAs at the practice level, which would end legislated caps on PA-to-physician supervision ratios and allow the clinicians to set optimal staffing at the local level
Until APRNs and PAs can buy their own malpractice insurance, policymakers should be sensitive to the malpractice liability of physicians who supervise advanced practice providers
The federal government should encourage best practices at the state level and fund SOP research
Researchers say these organizational and individual solutions can reduce overall physician burnout symptoms by 10%.
Physician burnout has reached crisis proportions, but there are several interventions that can ease the suffering, a recent review of the scientific literature on burnout shows.
"Rates of burnout symptoms that have been associated with adverse effects on patients, the healthcare workforce, costs, and physician health exceed 50% in studies of both physicians‐in‐training and practicing physicians," the researchers wrote.
"This problem represents a public health crisis."
Burnout is a work‐related malady with three characteristics: emotional exhaustion, depersonalization, and perception of reduced personal accomplishment.
The researchers say physician burnout has negative impacts on patient care, physician health, and healthcare system operations:
Patient care: medical errors, lower quality of care, longer recovery time, and lower patient satisfaction
Physician health: substance abuse, depression and suicidal ideation, poor self-care, and motor vehicle crashes
Healthcare system operations: physician productivity reductions, reduced patient access, and higher physician turnover
For healthcare organizations, there are significant financial losses associated with physician burnout. The cost to replace one physician can be more than $1 million depending on the specialty, the researchers wrote.
"Physician burnout may also increase healthcare expenditures indirectly via higher rates of medical errors and malpractice claims, absenteeism, and lower job productivity," they wrote.
Addressing physician burnout requires both organizational and individual interventions, the researchers wrote.
"Not only do both categories of approaches offer at least modest benefit, but both are necessary, and addressing physician burnout should be viewed as a shared responsibility across healthcare systems, organizations, institutions, and individual physicians."
However, organizational interventions have the highest potential to ease burnout, the researchers wrote.
"Individuals who choose to become physicians do not appear to be inherently more vulnerable to stress and burnout, emphasizing the importance of work‐related, organizational and healthcare system factors in the current physician burnout crisis."
The researchers identified five primary drivers for physician burnout: excessive workload, work inefficiency, work-home balance, loss of control, and loss of meaning from work. There are organizational and individual interventions for each driver.
Organizational interventions
Excessive workload: fair productivity goals, duty-hour limits, and appropriate job role assignments
Work inefficiency: optimize electronic medical records, shift clerical burdens to non-physician staff, and meet regulatory requirement appropriately
Work-home balance: respect home responsibilities in scheduling decisions, specify all required work tasks in assigned work hours, and support flexible work schedules
Loss of control: establish work requirements with physician engagement, and promote physician leadership and shared decision-making
Loss of meaning from work: promote core values, maximize patient time with physicians, foster physician communities, provide professional development opportunities, and offer leadership and awareness training about burnout
Individual interventions
Excessive workload: consider part-time status, and make informed practice choices to promote efficiency and physician satisfaction
Work inefficiency: prioritize and delegate tasks appropriately, and attend efficiency and workplace skills training
Work-home balance: reflect on life priorities and maintain self-care
Loss of control: attend stress management training, embrace positive coping strategies, and practice mindfulness
Loss of meaning from work: embrace positive psychology, recognize fulfilling work roles, practice mindfulness, and participate in small-group activities with other physicians to share work experiences
Healthcare organizations should consider burnout as a top metric, the researchers wrote. "At the organizational level, burnout assessment should be considered part of the 'dashboard' of tracked institutional performance measures, quality indicators, and leadership performance."
Once physician burnout is identified, interventions make a difference, they wrote.
With interventions, researchers have found decreases in the proportion of physicians with burnout symptoms: 14% for emotional exhaustion, 10% for overall burnout symptoms, and 4% for depersonalization.
Researchers find that patients at a hospital-based emergency department were 20% more likely to be admitted compared to patients at freestanding emergency departments.
Contrary to some critics, recent research shows that freestanding emergency departments may not admit patients for inpatient care at higher rates than hospital-based emergency departments.
The research, which was published this month in the American Journal of Emergency Medicine, was conducted at Cleveland Clinic's tertiary hospital-based emergency department (HBED) and two of the health system's freestanding emergency departments (FSEDs).
"These results show that a patient who presented to our HBED trended towards a 20% higher likelihood of admission than if a similar patient presented to our hospital-based FSED," the researchers wrote.
While the 20% variation was not considered statistically significant, it does represent a trend, according to the researchers.
There are two kinds of freestanding emergency departments:
Non-hospital, for-profit organizations operate independent freestanding emergency departments, which are not recognized as emergency departments by the Centers for Medicare & Medicaid Services.
Data for the 3,230-patient study was collected from 2015 health system statistics. The researchers focused on admission rates for four health conditions: chest pain, chronic obstructive pulmonary disease, asthma, and congestive heart failure.
The patients were closely split in their emergency department usage, with 53% using the HBED and 47% using the two FSEDs.
The researchers found that more of the HBED patients were admitted than the FSED patients:
Of the 1,708 patients who used the HBED, 49% (842) were admitted
Of the 1,522 patients who used the FSEDs, 42% (645) were admitted
In addition to the presenting condition, the researchers note several factors can influence an emergency medicine physician's decision to admit a patient. Those factors include convenience, transportation costs, availability of outpatient follow-up, social supports, and the need to 'turn' a bed to reduce waiting room time.
The researchers speculate there are at least two possible explanations for the observed higher rate of admissions from their HBED compared to the FSEDs.
1. Facility factor
An earlier study demonstrated that facility-related factors drive higher rates of admission from emergency departments.
"Having higher hospital occupancy rates, higher number of inpatient beds, being in an urban location, and having a level 1 or 2 trauma center were all associated with higher ED admission rates," the Cleveland Clinic researchers wrote.
For example, chest pain patients evaluated in an HBED could receive faster additional care as inpatients rather than waiting for a second set of lab work in the ED and an outpatient cardiac stress test.
2. 'Turn' temptation
HBED physicians may be under pressure to ease waiting room congestion and 'turn' beds.
"In a busy HBED the physician that does not 'turn' beds quickly can pose a risk to quality and patient satisfaction for the entire hospital system," the researchers wrote.
They say FSED physicians appear to have less bed-turning pressure.
"FSEDs tend to have lower volumes and shorter wait times. The pressure to 'turn' patients quickly is not as profound allowing the physician time to arrange follow-up and perform longer work ups."
"Based on our data, we are trying to document something that was previously unrecognized in the literature—a significant fraction of patients with clinical sepsis are not admitted to the hospital after presenting to the ED," says Ithan Peltan, MD, MSc, an attending physician at Intermountain and a leader of the research effort.
Peltan and his research team studied 8,239 adult ED sepsis patients at two tertiary hospitals and two community hospitals in Utah. The researchers found that 1,607 of the patients—19.5% of the total—were discharged rather than admitted to the hospital.
"The conventional wisdom assumes that all sepsis patients coming to the emergency department are being admitted, but our data shows some are being discharged. … We need a reconceptualization of who these patients are and how our care guidelines are being formulated," Peltan says.
Peltan's team presented the research last month at an American Thoracic Society conference in San Diego. Although the findings are preliminary, the researchers found that it is probably appropriate for some sepsis patients to be discharged from an ED into outpatient care.
"There was no significant difference in 30-day mortality for discharged versus admitted sepsis patients," the researchers wrote in the abstract they presented in San Diego.
Discharge safety uncertain
The researchers have shown that ED physicians are sending some patients home, and the next step is to characterize which sepsis patients are appropriate for ED discharge, Peltan says.
"We are not at the point where we can recommend routine discharge of any sepsis patients for outpatient management in the community."
He says there likely are several factors that determine whether a sepsis patient in the ED is a good candidate for discharge:
Patients who are not gravely ill and are not in need of intensive care intervention
Patients who are not at high risk of deterioration
Patients who can get the care they need as outpatients such as compliance with prescribed medications
Patients who can set and attend follow-up visits
A major element of safely discharging sepsis patients from EDs is developing a risk stratification methodology for sepsis similar to risk tools created for pneumonia, Peltan says. "We need that kind of risk-stratification tool for sepsis."
Risk stratification will help ED physicians sort out the best care path for sepsis patients, he says. "Who are the patients who need to be admitted? Who are the patients we might miss but need to be admitted? Which patients can be managed as outpatients?"
Physician decision-making varies
Peltan's team found significant variation in ED physician decision-making on whether to admit or discharge sepsis patients.
"We looked at physician-level behaviors and found some physicians did not discharge any of their sepsis patients and some physicians discharged nearly 40% of their sepsis patients," he says.
The decision-making variation is a valuable data point, Peltan says.
"Somewhere in the middle, there probably is a happy medium within that range of variation."
The final version of the Peltan team's research is slated for publication in 2019.
Nearly two-thirds of emergency medicine physicians work in urban communities, and the staffing mix in rural counties reflects an emergency physician shortage in those areas of the country.
Emergency department staffing patterns have a gaping urban-rural divide, new research shows.
In 2014 Medicare data, the distribution of emergency medicine physicians is strongly skewed toward urban areas. The researchers found urban counties had a much higher proportion of emergency physicians—63.9% compared to 44.8% in rural counties.
The shortage of emergency physicians in rural areas is severe, says M. Kennedy Hall, MD, MHS, lead author of the research and an emergency department physician at Harborview Medical Center in Seattle.
"Rural area patients are now considered a disparity population, and rural areas are faced with an ongoing problem of insufficient numbers of emergency medicine-specialty physicians to staff their emergency departments," Hall told HealthLeaders last week.
Hall says earlier research has shown that rural areas have fewer incentives and more barriers compared to urban areas for ER physicians seeking employment. That research found several factors influence job location choice:
Lifestyle
Access to amenities and recreation
ER volume and acuity
Family and spouse considerations
Access to specialists
Location of residency programs, which are mostly set in urban locations
In rural areas, research published in 2013 indicates there also are budgetary and strategic factors at play in the employment of ER physicians. Some hospital executives reported that low ER patient volume and acuity did not justify hiring emergency medicine specialists. The executives also reported satisfaction with the care provided by their non-emergency medicine physicians and advanced practice providers.
In rural areas, cost considerations discourage the hiring of emergency medicine physicians, Hall says.
"A provider mix with preferential hiring of non-emergency medicine physicians and advance practice providers at lower salaries can form a larger staff than a few highly paid emergency medicine-specialty physicians, which can in turn provide care to larger rural areas."
ER Staffing Mix Reflection of Urban-Rural Gap
Hall and his team found that rural areas have a much larger proportion of nonemergency physicians and advanced practice providers than urban areas.
In the study, which was published by Annals of Emergency Medicine, urban counties accounted for 50,157 emergency medicine clinicians, with ER physicians dominating the mix:
Emergency physicians, 63.9%
Non-emergency physicians such as family practice doctors, 12.0%
Advanced practice providers such as nurse practitioners and physician assistants, 24.1%
Rural counties accounted for 8,408 emergency medicine clinicians, with non-emergency physicians and advanced practice providers outnumbering emergency medicine physicians:
Emergency physicians, 44.8%
Non-emergency physicians, 28.3%
Advanced practice providers, 26.8%
In addition to lower staffing costs and easing the ER physician shortage, Hall says non-emergency physicians and advanced practice providers are a good fit at rural ERs with expanded care models.
He says non-ER physician providers can be essential caregivers in an integrated emergency medicine and primary care model.
"As emergency departments increasingly serve as health safety nets in rural areas—becoming both primary sources for hospital admission and hubs for unplanned acute care—a mixed ER staff of emergency physicians, non-emergency physicians, and advanced practice providers may be able to better collaborate on care coordination."
Under this model, non-emergency physicians and advanced practice providers give more comprehensive care than traditional ER models, says Hall, an assistant professor at the University of Washington School of Medicine in Seattle.
"The varied and usually primary care-centered training and skills of non-emergency medicine physicians and advanced practice providers serve as a valuable asset in addressing patients' health over a longer term than typically considered in traditional ER models."
Hall says hospital executives should consider four factors when deciding ER staffing targets:
Whether patient volume is large enough to generate a cost-neutral or cost-saving employment of emergency medicine physicians
Whether budget considerations dictate the hiring of non-emergency physician staff to serve a coverage area adequately
Whether the care model favors emergency physicians or a more balanced mix of healthcare providers
Whether there is the capability to provide training and experience for non-ER physicians who lack emergency medicine board certification
A North Carolina health system finds racial disparity in pneumonia patient readmission rates, identifies causes of problem, launches interventions, and eliminates gap.
In less than two years, Novant Health eliminated disproportionately higher hospital readmission rates for African-American pneumonia patients, who had readmission rates 4% higher than Caucasian patients.
The impetus for the initiative came in April 2016, when Novant President and CEO Carl Armato signed the American Hospital Association's #123for Equity Campaign pledge.
"That's really what jumpstarted this project," says Regina Fambrough, program manager for diversity and inclusion.
After signing the equity pledge, one of the first steps taken to address diversity gaps at Novant was an examination of readmissions data at the health system, which features 11 acute care hospitals.
In the analysis, readmissions were segmented by race, ethnicity, language, gender, age, and payer source.
"What we found was there was a disparity, and it could continue to get worse. The readmission rates for African-American pneumonia patients were 4% higher than for the Caucasian population," says Tanya Blackmon, executive vice president and chief diversity and inclusion officer.
Novant closed the gap last year:
In the third quarter of 2017, the readmission rate disparity was cut in half to 2%
In the fourth quarter of 2017, readmission rates for pneumonia showed no disparity
Finding Disparity Causes
In May 2016, the Winston-Salem-based health system formed the Pneumonia Readmissions Team to study the source of the disparity and to launch interventions aimed at closing the readmissions gap.
The Pneumonia Readmissions Team, which includes Blackmon and Fambrough, is an interdisciplinary panel that meets monthly.
The panel includes a hospitalist physician, the health system's transcultural health manager, the director of case management, a care coordination representative, nursing, pharmacy, a pulmonary navigator, and a data and analytics representative.
The team's data analysis, which included 100 comprehensive medical record reviews, revealed two primary causes of the African-American pneumonia readmissions gap:
For patients who were readmitted, there was often fewer case management assessments compared to other patients and few people to provide home care.
Care coordinator calls to African-American pneumonia patients were problematic. For example, when the transcultural health manager called these patients, Blackmon said she found they didn't realize the calls were from a care coordinator.
Novant has launched several initiatives to close the African-American pneumonia readmissions gap, such as:
Collaboration between case management and electronic health record report writers to redesign patient lists to encourage assessments at discharge, which has helped boost case management assessments 22%
Warm handoff: Discharge nurses tell the patient that the care coordination team will be following up by phone and to expect a call
Pulmonary navigators, who were hired to work closely with pneumonia and COPD patients, organize timely patient referrals to the care coordination team for follow-up postdischarge
In 2017, Novant launched new scheduling for patient follow-up visits, with follow-up visits set before hospital discharge. The new scheduling drove a 12% improvement in African-American pneumonia patients receiving a follow-up visit within seven days of discharge, and there was a 25% increase in patients keeping appointments.
Blackmon says Novant expects to have return on investment numbers for the initiative later this year, but says the effort is generating cost savings.
"We are all in agreement that there are avoidable costs here—when you are readmitting a patient, you may not get reimbursed for the readmission," she says.
In February, the Centers for Medicare & Medicaid Services recognized Novant's pneumonia disparity work with the inaugural Health Equity Award. Kaiser Permanente also received the award, which was presented in Baltimore.
