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Objectives: The objective was to describe transfers out of hospital-based emergency departments (EDs) in the United States and to identify different characteristics of sending and receiving hospitals, travel distance during transfer, disposition on arrival to the second hospital, and median number of transfer partners among sending hospitals.Methods: Emergency department records were linked at transferring hospitals to ED and inpatient records at receiving hospitals in nine U.S. states using the 2010 Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases and State Inpatient Databases, the American Hospital Association Annual Survey, and the Trauma Information Exchange Program. Using the Clinical Classification Software (CCS) to categorize conditions, the 50 disease categories with the highest transfer rates were studied, and these were then placed into nine clinical groups. Records were included where both sending and receiving records were available; these data were tabulated to describe ED transfer patterns, hospital-to-hospital distances, final patient disposition, and number of transfer partners.Results: A total of 97,021 ED transfer encounters were included in the analysis from the 50 highest transfer rate disease categories. Among these, transfer rates ranged from 1% to 13%. Circulatory conditions made up about half of all transfers. Receiving hospitals were more likely to be nonprofit, teaching, trauma, and urban and have more beds with greater specialty coverage and more advanced diagnostic and therapeutic resources. The median transfer distance was 23 miles, with 25% traveling more than 40 to 50 miles. About 8% of transferred encounters were discharged from the second ED, but that varied from 0.6% to 53% across the 50 conditions. Sending hospitals had a median of seven transfer partners across all conditions and between one and four per clinical group.Conclusions: Among high-transfer conditions in U.S. EDs, patients are often transferred great distances, more commonly to large teaching hospitals with greater resources. The large number of transfer partners indicates a possible lack of stable transfer relationships between U.S. hospitals.ACADEMIC EMERGENCY MEDICINE 2015;22:157-165

Repeated emergency department (ED) visits by HIV-infected persons may signify poor access to care or treatment from inexperienced ambulatory providers. We examined features of 157 clinics following 6820 HIV-infected patients and associations with repeated (> or =2) ED visits by these patients in the year before their first AIDS diagnosis. Patient clinical and health care data came from 1987-1992 New York State (NYS) Medicaid files and clinic data came from interviews of clinic directors. The HIV/AIDS experience of each study patient's clinic was measured as the annual number of Medicaid enrollees newly diagnosed with AIDS who were contemporaneously followed by the patient's clinic. Repeated ED use was observed for 24%. The adjusted odds ratio (AOR) of repeated ED visits was reduced for patients in clinics with a physician on-call (0.77; 95% confidence interval [CI] = 0.65, 0.92), evening or weekend clinic hours (0.77; 95% CI = 0.64, 0.93), or >50 AIDS patients/year in 1987-1988 (0.56; 95% CI = 0.44, 0.71) versus fewer patients in those years. Patients in clinics with more than one feature promoting accessibility or HIV expertise had a greater reduction in their AOR of repeated ED use. HIV-infected patients in clinics with greater accessibility and HIV expertise rely less on the ED for care.

To be consistent with pay-for-performance principles and make claims data more useful for quality assurance, incorporating POA coding into DRG-PPS could produce sizable savings for Medicare.

We evaluated factors associated with low birth weight (LBW) in an HIV-infected cohort (n = 772) and a general sample (n = 2,377) of women delivering a live singleton in federal fiscal years 1989 and 1990 while enrolled in New York State Medicaid. The association of LBW and HIV infection was studied in logistic models, controlling for illicit drug use, demographic characteristics, adequacy of prenatal care, and medical risk factors. Overall, 29% of the HIV-infected women had a LBW infant compared to 9.3% of the general sample (p < 0.001). The adjusted odds of LBW for HIV-infected women were twofold higher than for uninfected women [odds ratio (OR) = 2.04 and 95% confidence interval (Cl) = 1.54, 2.69]. Odds of LBW were also increased for illicit drug users (OR = 2.16; 95% CI = 1.59, 2.94), cigarette smokers (OR = 1.81; 95% CI = 1.37, 2.39), and African-American versus non-Hispanic white women (OR = 1.89; 95% CI = 1.31, 2.72). Lower odds appeared for women with adequate prenatal care (OR = 0.54; 95% CI = 0.42, 0.68). Among only women with full-term deliveries, the association of HIV with LBW remained strong as we found nearly threefold greater odds of LBW for HIV-infected women. This study indicates that HIV-infected women have an increased risk of bearing a L.BW infant, even after adjusting for the effects of drug use, health care delivery, and other social and medical risk factors.

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Asthma is an important condition to study in the Medicaid population because it is the most frequent reason for hospital admission of Medicaid children, with rates substantially higher than those of non-Medicaid children. This study addressed how the quality of hospital care provided to children with asthma on Medicaid compares with that provided to privately insured children. Children inpatient records were studied in California, Georgia, and Michigan, comparing the care that was provided to standards created by a national panel of physician experts. Process-of-care analysis showed that Medicaid children in each state were more likely than privately insured children to be discharged on suboptimal medication regimens. This study concluded that hospitals serving Medicaid children, at least in these three states, are providing asthma inpatient care of fairly comparable quality to that of privately insured children. However, there remain significant problems surrounding outpatient medication regimens and follow-up care.