No clear evidence that diverting patients from emergency departments curbs overcrowding

Press Release:

Given the considerable costs of providing alternative sources of care, there is remarkably little good quality evidence to back this approach, conclude the researchers.

Redirecting low need patients from emergency care departments to alternative sources of care, has been proposed as a potential solution to tackling the overcrowding that often occurs in these facilities.

But it isn’t clear whether this strategy actually works or is safe. The researchers therefore systematically reviewed and pooled the data from 15 relevant studies, evaluating the impact of redirecting patients to alternative sources of care before reaching, or once in, an emergency care department.

No strong evidence emerged to either back or refute the safety and effectiveness of this strategy, the data analysis showed.

What’s more, the proportion of patients suitable for diversion was relatively low and a considerable proportion of those who were suitable didn’t want to use alternative sources of care either.

Redirecting patients to alternative sources of care was twice as common among those who had already reached an emergency care department.

But compared with those who weren’t redirected, doing this before the patient reached hospital didn’t cut the proportion transferred to emergency care.

Nor did it stop them subsequently using emergency care services: their patterns of use didn’t differ from those of patients who weren’t redirected.

While only three studies looked at the costs involved, none found any difference in total healthcare spend between patients who were diverted away from emergency care departments and those who weren’t.

The overall quality of the published evidence was not particularly good. This included varying definitions of low need; limited information on the outcomes of patients given standard care; the numbers of patients willing and able to accept alternative sources of care; or the costs involved.

“Despite the clear resource implications for implementing [emergency department] diversion strategies, including training and hiring additional staff, costs of implementing the diversion strategies were infrequently reported,” they write.

All this makes it difficult to draw definitive conclusions, they caution, concluding: “At this time there is insufficient evidence to recommend the implementation of diversion protocols as effective and safe strategies to address emergency department overcrowding.”

And in a linked podcast in discussion with the journal’s editor, Professor Ellen Weber, lead author, Dr Brian Rowe, University of Alberta, isn’t convinced ‘the juice is worth the squeeze.’

“I am not sure the efforts involved in doing diversion are really worth all the costs, time, and surveillance,” he says. And not all emergency department patients are the same, although the diversionary strategies to date tend to assume that they are, he says.

Surveys in Canada indicate that patients have often tried many other options before coming to an emergency department, or that they are there because the health system has failed them, he suggests.

What’s more, he adds, patients like the ‘one-stop shop’ service provided by hospitals, and younger patients often don’t register with a family doctor, leaving them with few other options.

Wage index reform could buoy rural hospitals

From Modern Healthcare:

Providers, hospital associations and policy experts believe revamping the tool the CMS uses to set hospital payments could be a lifeline for rural hospitals.

HHS’ Office of Inspector General suggested changes to the wage index in a new report that found holes in the system that has resulted in millions of dollars of improper payments to hospitals across the country. The flawed calculations have created a series of winners and losers whose reimbursement levels are minimally tied to wages, labor costs and cost of living, as the index initially intended.

Audit: Privatized Medicaid is saving Iowa millions of dollars. Democrats aren’t convinced

From the Register:

After two years of releasing see-sawing estimates, Iowa Medicaid leaders are correctly calculating how much the state is saving by hiring private companies to manage the state’s $5 billion Medicaid program, the state auditor concluded Monday.

State Auditor Mary Mosiman said the May 2018 estimate of $141 million in annual savings was more accurate than earlier state estimates of $234 million and $47 million.

Access Denied Part Two: How Insurance Coverage Denials Can Block Access to Preventive and Emergency Care

From the Doctor-Patient Rights Project:

Health insurers are using opaque and inconsistent standards to deny coverage for both preventive medical and emergency services, according to a new report from healthcare advocacy coalition the Doctor-Patient Rights Project (DPRP). The report contains previously unreleased data illustrating the rate at which insurers are denying access to medical screening and testing and also examines an insurer policy of denying coverage for emergency care by retroactively claiming an emergency service was “avoidable.”

The new report, Access Denied Part Two: How Insurance Coverage Denials Can Block Access to Preventive and Emergency Care, examines how insurers are restricting access to medical services and treatments across some stages of care. The report also looks at how those coverage denials discourage early detection and intervention of chronic illnesses, thereby increasing costs for patients and putting more of a burden on emergency departments and the health care system as a whole.

Teva prices EpiPen generic at $300, same price as Mylan generic

From Reuters:

Teva Pharmaceutical Industries Ltd said on Tuesday it launched its generic version of Mylan NV’s EpiPen at the wholesale price of $300 – the same price as Mylan’s generic version of the emergency allergy shot.

Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study

From the Annals of Emergency Medicine:

Study objective

Although both succinylcholine and rocuronium are used to facilitate emergency department (ED) rapid sequence intubation, the difference in intubation success rate between them is unknown. We compare first-pass intubation success between ED rapid sequence intubation facilitated by succinylcholine versus rocuronium.


We analyzed prospectively collected data from the National Emergency Airway Registry, a multicenter registry collecting data on all intubations performed in 22 EDs. We included intubations of patients older than 14 years who received succinylcholine or rocuronium during 2016. We compared the first-pass intubation success between patients receiving succinylcholine and those receiving rocuronium. We also compared the incidence of adverse events (cardiac arrest, dental trauma, direct airway injury, dysrhythmias, epistaxis, esophageal intubation, hypotension, hypoxia, iatrogenic bleeding, laryngoscope failure, laryngospasm, lip laceration, main-stem bronchus intubation, malignant hyperthermia, medication error, pharyngeal laceration, pneumothorax, endotracheal tube cuff failure, and vomiting). We conducted subgroup analyses stratified by paralytic weight-based dose.


There were 2,275 rapid sequence intubations facilitated by succinylcholine and 1,800 by rocuronium. Patients receiving succinylcholine were younger and more likely to undergo intubation with video laryngoscopy and by more experienced providers. First-pass intubation success rate was 87.0% with succinylcholine versus 87.5% with rocuronium (adjusted odds ratio 0.9; 95% confidence interval 0.6 to 1.3). The incidence of any adverse event was also comparable between these agents: 14.7% for succinylcholine versus 14.8% for rocuronium (adjusted odds ratio 1.1; 95% confidence interval 0.9 to 1.3). We observed similar results when they were stratified by paralytic weight-based dose.


In this large observational series, we did not detect an association between paralytic choice and first-pass rapid sequence intubation success or peri-intubation adverse events.

Boston company introduces mental health pilot program at Walmart

From Becker’s:

Beacon Health Options, a clinical mental health and substance use disorder management company in Boston, aims to bring affordable mental healthcare to patients across the U.S. through the creation of a new retail health clinic, The Boston Globe reports.

Beacon opened its first retail health clinic in a Carrollton, Texas-based Walmart and plans to open more locations nationwide to increase patients’ access to mental health services.

The clinic, which has been operational for roughly one week, is staffed by one licensed social worker and offers treatment for anxiety, depression, grief and relationship issues, among other stressors. Patients can walk in to request an appointment, or sign up online or over the phone. If the clinic becomes busy, patients also have the option to speak to other Beacon care professionals remotely by Skype or other services, the report states.