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MedStar Healthcare Delivery Research Network

Healthcare Delivery Research at the Research Institute

About the MedStar Healthcare Delivery Research Network

The MedStar Healthcare Delivery Research Network was formed in 2010 as the catalytic driving network to impact how MedStar Health clinically re-engineers the delivery of care to achieve value, quality, and patient satisfaction. To achieve this goal, the Network conducts patient-centered research on the delivery of care that can be applied and disseminated to improve the health of the general population, including those served by the MedStar Health System. 

Since its inception, the MedStar Healthcare Delivery Research Network has grown to realize consistent and exponential growth. The Network received several prominent national grants including being selected as one of 13 prime organizations in the Agency for Healthcare Research and Quality’s Accelerating Change and Transformation in Organizations and Networks (ACTION) network.  Many of the awarded MedStar Healthcare Delivery Research Network projects have informed national standards and/or policy for care delivery. Through the Network, MedStar Health, a real-world learning health system, has taken an active role in being the healthcare system where the future of healthcare is created, implemented, and disseminated to the rest of the nation.

MedStar Center for Health Equity Research
The multidisciplinary home for health equity research, scholarship, and community engagement.

MedStar Center for Health Economics, Systems, and Policy Research
Conducting research on healthcare organization, delivery, payment, and costs.
MedStar Institute for Quality and Safety
Designing, implementing, and testing innovations to improve the future of health for all Americans.
MedStar National Center for Human Factors in Healthcare
Generating and disseminating new knowledge about how critical healthcare challenges are identified, tracked, and addressed in order to better support clinicians and enhance patient safety.

MedStar-Georgetown Surgical Outcomes Research Center
Contributing to the science on disparities in surgical oncology care among vulnerable populations including older adults, ethnic and racial minorities, those with comorbidities, and persons in rural settings.

 

MedStar Center for Health Equity Research

The MedStar Center for Health Equity Research is a multidisciplinary home for health equity research, scholarship, and community engagement. Established by the MedStar Health Research Institute, the vison of the Center is a community in which all individuals (regardless of factors such as race/ethnicity, gender, age, socioeconomic status or geographic location) have the same opportunity to achieve optimal health.

The mission of the Center is to advance health, particularly for underserved populations, by conducting collaborative research and providing education to empower, inform, and transform health-- for patients and families, providers, communities, and the health system. Acknowledging that health equity is complex, multifactorial and requires expertise and perspectives from multiple disciplines, the Center brings together a diverse team of researchers, clinicians, and community partners collaborating to achieve a true community-engaged research approach. The Center and its members are actively engaged in research to directly address health disparities, health inequity, and the social determinants of health across multiple domains. This includes digital health, patient safety, patient and family engagement, diagnostic error, diabetes and other chronic disease management, maternal and child health, and behavioral health.

The MedStar Center for Health Equity Research also leverages partnerships with multiple community-based organizations, local and state health departments, and with academic partners including the Georgetown University Racial Justice Institute, and the Georgetown Health Justice Alliance.

Investigative Team

deliya wesley

Deliya Wesley, PhD, MPH
Scientific Director, Center for Health Equity Research

Angela D. Thomas, DrPH, MPH, MBA
Assistant Vice President, Healthcare Delivery Research
Executive Lead, Safe Babies Safe Moms

This project applies the science of human factors with a health equity lens to identify patient needs when accessing and interacting with patient portals.

Background Patient portals potentially serve as a platform for patients to easily access their health information and more easily communicate with their clinician, if designed and developed appropriately for the user. When patients use portals it also affords the opportunity to have their health information preserved over time. Despite these benefits, the majority of the US population does not access or engage with patient portals. With the Office of the National Coordinator for Health Information Technology now mandating open application programming interfaces (APIs), which will allow for the development of patient portals that can receive data from any electronic health record vendor product, the effective design of portals for all users is now even more critical. Many patient portals suffer from poor usability and do not provide patients with the information they need in an intuitive format. Further, patient needs vary by demographics and health status. The objective of this research is to identify and characterize the factors differentiating patient portal users from non-users within five population subgroups, and to develop clear design guidelines to represent their needs.
Approach/Methods A large cross-sectional survey will be conducted of diverse patient portal users and non-users, by sampling from novel crowd-sourcing platforms (for broad reach) and patients within a large diverse health system. Identified user preferences to develop personas will be applied followed by a usability analysis of common patient portal products to determine whether these products meet the identified user needs. The outputs will include user-centered guidelines for patients across the spectrum of usage and portal engagement. This has the potential to improve patient portals based on a deep understanding of patient needs, identification of the shortcomings of current patient portals, and learnings from those systems with successful adoption (incentivized or otherwise).
Results In progress
Impact In progress

This pilot establishes feasibility of an optimized Diabetes Colored-Eco Genetic Relationship Maps (D-CEGRM) to map and identify nuances in social networks for black patients with diabetes.

Background Poor self-management of diabetes leads to devastating secondary complications and mortality. Black patients display poorer self-management behaviors compared with patients of other races and ethnicities. Social support and social networks are important social determinants of health. Social support refers to the supportive actions of others that promote coping or protect against life stress. Social networks refer to linkages between people that may or may not provide social support and that may serve other functions (e.g., social influence, companionship). Whether effective self-management among black diabetes patients is due to social support alone or to specific social network attributes has yet to be evaluated. The long-term goal of this program of research is to develop an innovative predictive model for diabetes self-management using social support and social network analysis. It is critical to develop a means to identify the patients most in need of intervention by understanding the nuanced diabetes self-management behaviors that drive unfavorable outcomes for black patients. The short-term goal of this project is to generate pilot data on the characteristics and use of social networks among black diabetes patients and the relationship to social support, general health status, and diabetes self-management.
Approach/Methods The Diabetes-Colored Eco-Genetic Relationship map is a tool adapted and validated for eliciting information about how individuals use their social networks to support their diabetes self-management efforts. The objective is to develop an interactive digital prototype of the Diabetes-Colored Eco-Genetic Relationship map in order to:
  1. Characterize social networks among black patients with diabetes
  2. Gain experience in using the interactive Diabetes-Colored Eco-Genetic Relationship map (with traditionally underrepresented patient populations)
  3. Examine how social support and social networks correlate with other standard measures (e.g. perceived general health status) and reported self-management behaviors
Results Final analysis almost complete
Impact In progress

The purpose of this project was to determine if race differences exist in voluntarily reported harmful patient safety events in a large healthcare system.

Background The Institute of Medicine’s 1999 “To Err is Human” report identified unacceptable levels of unintended harm in medicine and reported 44,000-98,000 preventable deaths per year 1. Over time, many healthcare organizations have incorporated high reliability organization principles into safety efforts, including the use of multiple platforms for event surveillance as employed in other high-risk industries such as aviation2. While race differences in health outcomes are widely documented3, little is known about race differences in adverse patient safety events. Further, no literature exists that explores race differences in adverse patient safety events across multiple event reporting systems.
Approach/Methods From July 1, 2015 to June 30, 2017, employees in a large mid-Atlantic healthcare system voluntarily reported harmful patient safety events by type using a Patient Safety Event Management System. Inpatients, outpatients, and observation patients were identified as “Black”, “White”, or “Other” (N=5,038). Using retrospective analysis and Chi-Square Goodness of Fit, comparisons of race proportions were conducted to determine differences at the health system level, by hospital, by event type, and by severity.
Results Significant race differences existed: 1) overall with higher proportions of Whites and lower proportions of Others in the Patient Safety Event Management System; 2) by type across races; 3) in six hospitals across races; and 4) by type and by hospital for Blacks and Whites. All differences were significant at p<0.05.
Impact This study led to additional funding from the Charles and Mary Latham Fund to further understand these findings using chart abstraction via the Institute for Healthcare Improvement’s Global Trigger Tool methodology.
Resources
  1. 1. IOM. To Err Is Human. Washington, D.C.: National Academies Press; 1999. doi:10.17226/9728.
  2. Chassin MR, Loeb JM. High-reliability health care: Getting there from here. Milbank Q. 2013;91(3):459-490. doi:10.1111/1468-0009.12023.
  3. IOM. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. (Smedley BD, Stith AY, Nelson AR, eds.). Washington, DC: The National Academies Press; 2002.
Publication

 


MedStar Center for Health Economics, Systems, and Policy Research

The Center for Health Economics, Systems, & Policy Research focuses on healthcare organization, delivery, payment, and costs. It includes analyses of healthcare markets, health policy, health care delivery models, outcome measurement, social determinants of health, and transitions across healthcare settings. The center also examines the effects of global budgeting payment reform on healthcare delivery. 

Research areas of focus:

  1. Total costs of care 
  2. Healthcare for Medicare and Medicaid populations 
  3. Hospital Utilization 
  4. Health Care Quality 
  5. Transitions of Care 

Investigative Team

Derek M. DeLia, PhD
Director of Health Economics & Health Systems Research

Jessica E. Galarraga 

Jessica E. Galarraga, MD, MPH
Physician Investigator, MedStar Health Research Institute
Associate Medical Director, Quality Data Science, MedStar Health

Erin Rand-Giovannetti, PhD
Scientific Director
Health Economics and Aging Research (HEAR)

Jason Brown, PhD
Delivery System Science Fellow

dana-h-frank

Dana Frank, MD
Chair Department of Medicine MedStar Good Samaritan & Union Memorial Hospital

George-Hennawi

George Hennawi, MD
Director, Geriatrics at MedStar Good Samaritan Hospital

Sean Huang, PhD
Associate Professor
Department of Health Systems Administration
Georgetown University

   

This project evaluated the New Jersey Medicaid Accountable Care Organization Demonstration Project, provided technical analysis for the development of shared savings mechanisms, and disseminated lessons learned throughout the nation.

Background The Affordable Care Act stimulated the creation of Accountable Care Organizations in Medicare and private insurance. Some states developed their Medicaid Accountable Care Organization models. New Jersey was an early adopter of the Medicaid Accountable Care Organization approach. The New Jersey model included a unique combination of flexibility for Accountable Care Organizations to develop their own performance goals and metrics while maintaining strong state oversight of care provided to vulnerable populations.
Approach/Methods This study used mixed quantitative and qualitative methods to evaluate the Demonstration activities including the integration of health and social services, Accountable Care Organizations engagement with managed care plans, and development of information systems to redesign care processes. Statistical simulation methods were used to understand the effect of altering different technical parameters in shared savings arrangements such as the treatment of spending for very high-cost outlier patients.
Results

Commonly used shared savings formulas are highly sensitive to statistical variation that misclassifies whether Accountable Care Organizations should be rewarded for reducing healthcare spending or potentially penalized for increasing spending. Accuracy in savings performance measurement can be improved by designing contracts that more directly account for Accountable Care Organizations -specific factors such as historical spending performance and exclude healthcare costs that are beyond the Accountable Care Organization’s focus or control such as trauma care or extreme outlier spending (e.g., pediatric cancer, renal failure).

Within the Demonstration, Accountable Care Organizations struggled to achieve shared savings and sometimes repositioned their arrangements with managed care plans into service contracts with performance metrics but no financial risk. The Accountable Care Organizations did not show population-level impacts in healthcare quality or health improvement measures. This is largely due to a shift in emphasis away from broad care coordination activities toward intensive case management for a relatively small number of medically and socially complex patients. As a result, the Accountable Care Organizations evolved into community health coalitions focused on coordinating and enhancing a wide range of activities in partnership with state government, private health systems, community leaders, and managed care plans. This evolution led the state to reimagine a role for these coalitions to serve as regional partners in the implementation of state-directed population health initiatives.

Impact The project provided technical analysis that influenced the development of Medicaid shared savings formulas used within the Demonstration by New Jersey state government and a private arrangement between a Medicaid Accountable Care Organizations and managed care plan. Evaluation work influenced the development of legislation that transitions the Demonstration Accountable Care Organizations into Regional Health Hubs that coordinate health and social service interventions to advance the state’s public health goals for low-income and other vulnerable populations. Findings were also disseminated to policymakers and stakeholders in states that have developed or are considering the development of Accountable Care Organizations approaches in their Medicaid programs.
Funding Agency Agency for Healthcare Research and Quality, The Nicholson Foundation
Publications Derek DeLia & Michael J. Yedidia. “The Policy and Practice Legacy of the New Jersey Medicaid ACO Demonstration Project”. Journal of Ambulatory Care Management 43(1): 2-10, 2020.
Derek DeLia. “Spending Carveouts Substantially Improve the Accuracy of Performance Measurement in Shared Savings Arrangements: Findings from Simulation Analysis of Medicaid ACOs.” Inquiry: The Journal of Health Care Organization, Provision, and Financing 54: 1-11, 2017.
Derek DeLia. “Monte Carlo Analysis of Payer and Provider Risks in Shared Savings Arrangements.” Medical Care Research and Review 73(5): 511-531, 2016.
Derek DeLia, Michael Yedidia, & Oliver Lontok. Update on Operations and Care Management Strategies in the New Jersey Medicaid Accountable Care Organization Demonstration Project. Rutgers Center for State Health Policy: New Brunswick, NJ, November 2018.
Derek DeLia, Rizie Kumar, Jose Nova, Kristen Lloyd, & David Goldin. Spending and Utilization Indicators in the New Jersey Medicaid Accountable Care Organization Demonstration Project. Rutgers Center for State Health Policy: New Brunswick, NJ, November 2018.
Derek DeLia, Michael Yedidia, & Oliver Lontok. Year 1 of the New Jersey Medicaid Accountable Care Organization Demonstration Project: Assessment of Operations and Care Management Strategies. Rutgers Center for State Health Policy: New Brunswick, NJ, February 2017.
Derek DeLia. “The NJ Medicaid ACO Demonstration – 2018 Update.” National Healthcare Web Summit hosted by Medical Care On Line (MCOL). April 11, 2018.
Derek DeLia. Panelist for “Proven Approaches to Managing High-Risk Patients” at the Eighth National Accountable Care Organization Summit. Arlington, VA. June 29, 2017.
Derek DeLia. “NJ Case Study: The NJ Medicaid ACO Demonstration.” National Healthcare Web Summit hosted by Medical Care On Line (MCOL). June 2, 2017.
Derek DeLia. “Medicaid ACOs in New Jersey.” Presentation at the National Health Policy Forum (NHPF) on Accountable Care Organizations in Medicaid: Learning from Leading-Edge States. Washington, DC. December 11, 2015.
Derek DeLia. “Analytic Support for Payment and Delivery Reform in New Jersey Medicaid.” Presentation at the State-University Partnership Learning Network (SUPLN) Annual Meeting. Washington, DC. November 20, 2015.
Derek DeLia. Panelist for “Sharing of New Jersey Medicaid Payment Reform Initiative.” Health Care Payment Learning & Action Network (HCP-LAN). National Webinar October 15, 2015.
Derek DeLia. “The New Jersey Medicaid ACO Demonstration Project: Design and Evaluation.” National webinar hosted by the Center for Healthcare Strategies. Hamilton, NJ. September 28, 2015.
Derek DeLia. Panelist for “Variation and Financial Performance Metrics.” The Sixth National Accountable Care Organization Summit. Washington, DC. June 18, 2015.
Derek DeLia. Panelist for “Random Variation and Risk Adjustment.” The Fifth National Accountable Care Organization Summit. Washington, DC. June 18, 2014.
Derek DeLia. “The New Jersey Medicaid Accountable Care Organization Business Planning Toolkit.” Webinar co-presented with Rob Houston, Tricia McGinnis, Rachel Cahill, and Bruce Dees. July 12, 2013.
Derek DeLia. “How Exactly Will Providers Be Held Accountable? Emerging Methods of ACO Performance Measurement.” Corporate Research Group Webinar Series. November 14, 2012; March 13, 2013.

This project evaluated the effects of global budgeting reform on admissions from the emergency department, overall and by encounter type.

Background In 2014, Maryland launched a population-based payment model that replaced fee-for-service payments with global budgets for all hospital-based services. This “global budget revenue” program gives hospitals strong incentives to tightly control patient volume and meet budget targets.
Approach/Methods Medical record and billing data were used to examine adult emergency department encounters from January 1, 2012 to December 31, 2015 in 25 hospital-based emergency departments, including 10 Maryland global budget revenue hospitals, 10 matched non-Maryland hospitals (primary control), and 5 Maryland Total Patient Revenue hospitals (secondary control). Total patient revenue hospitals adopted global budgeting in 2010 under a pilot Maryland program targeting rural hospitals. Difference-in-differences analyses were conducted for overall emergency department admission rates, emergency department admission rates for ambulatory care sensitive conditions and non-ambulatory care sensitive conditions, and for clinical conditions that commonly lead to admission.
Results In 3,175,210 ED encounters, the emergency department admission rate for Maryland global budget revenue hospitals fell by 0.6% (95% confidence interval: -0.8, -0.4) compared to non-Maryland controls after global budget revenue implementation, a 3.0% relative decline, and fell by 1.9% (95% confidence interval: -2.2, -1.7) compared to total patient revenue hospitals, a 9.5% relative decline. Relative declines in emergency department admission rates were similar for ambulatory care sensitive conditions and non- ambulatory care sensitive conditions encounters. Admission rate declines varied across clinical conditions.
Impact This study identified how, among the all-payer patient population, implementation of the global budget revenue model led to statistically significant decline in emergency department admission rates within its first two years, with declines in emergency department admissions most pronounced among encounters for diabetes.
Funding Agency Emergency Medicine Foundation
Resource https://www.leadersedge.com/healthcare/global-budgets-testing-ground
Publication https://www.ncbi.nlm.nih.gov/pubmed/31455571

This qualitative study examined care coordination processes in the emergency departments.

Background Seamless care transitions are a major priority for health systems. Population-based payment reforms implemented in Maryland, termed the global budget revenue program, has incentivized a shift towards non-hospital care and lower admissions. Emergency department-based care coordination can have an important role in meeting these goals. This study examined emergency department care coordination processes across Maryland and identified specific interventions. This study also examined perceptions on the effectiveness of care coordination and the influence of global budget revenue that gives hospitals strong incentives to tightly control patient volume and meet budget targets.
Approach/Methods A qualitative study was conducted using semi-structured interviews to examine emergency department care coordination processes, initiatives, and perceptions among emergency department physician leadership and care coordination staff. Participants were purposively recruited across Maryland emergency departments to ensure diverse representation of emergency departments in annual volume (range: 12,000-90,000), system affiliation, trauma level, and metropolitan status. A total of 25 semi-structured interviews encompassing 15 different sites were conducted, with an interdisciplinary group representative of the emergency department care coordination process: physician leadership (n=15) and care coordination staff (n=10). Interview questions covered domains pertaining to different facets of the care coordination process as well as perceptions of the influence of global budget revenue. Participant’s answers were coded independently using thematic analysis by two members of the research team, with coding disagreements assessed and resolved by the full research team.
Results

Across all sites, there was an average of 4.3 full time equivalents of care coordination staff coverage with significant variation (range: 1 – 12 full time equivalents). The most common care coordination services provided were implementing care plans for high utilizers and arranging outpatient substance abuse services, home health services, and home medical equipment. The number of initiatives implemented to improve emergency department care coordination ranged from 0 to 7 initiatives per site. The most common initiative was a process to link substance abuse patients with peer counselors and rehabilitation resources (9 sites).

Participants perceived emergency care coordination as effective in facilitating safer discharges and addressing social determinants of health; however, adequate access to outpatient clinicians was a significant barrier. (Table 1) The majority of emergency department physician leaders (9/15) perceived global budget revenue as having a mixed impact, both positive and negative, on care transitions. The majority noted that emergency department “care coordination is a beneficial offshoot of global budget revenue...now hospitals are motivated to put money into [care coordination] resources.” However, participants also noted that with global budget revenue “we are working extra hard for extra-long to not admit patients” and “global budget revenue has negatively impacted emergency department length of stay.”

Impact Across Maryland, there is a broad range of emergency department care coordination services provided and significant variation in the organizational processes to implement them. However, a prevailing theme is that global budget revenue has led to investments to improve emergency department care coordination. Further research is needed to examine the association of the various approaches to emergency department care coordination with patient outcomes.
Funding Agency Emergency Medicine Foundation

This study evaluated the effects of payments reform with global budgets on emergency department utilization and quality.

Background In 2014, Maryland launched an innovative statewide reform that replaced fee-for-service hospital payments with a “global budget revenue” model. Global budget revenue prospectively determines an annual budget for each hospital, incentivizing hospitals to closely meet revenue targets and prevent avoidable admissions. Prior research conducted by the center demonstrated a relative decline in emergency department admission rates among global budget revenue hospitals compared to controls that remained fee-for-service as well as post- global budget revenue investments in emergency department care coordination. In this study, global budget revenue’s effects on all-payer emergency care utilization and quality, including emergency department visits, emergency department returns, and morbidity and mortality among emergency department returns were examined.
Approach/Methods An interrupted time series analysis was conducted with difference-in-differences comparisons using Healthcare Cost Utilization and Project data from 2012 to 2015 from Maryland, the experimental state, and New York, the control state which did not implement global budgets. Generalized linear model was used to identify global budget revenue’s effects on emergency department visits/1,000 population and a linear probability model to identify global budget revenue’s effects on emergency department return rates at 72-hours and 9-days. The rate of hospitalization and in-hospital mortality among emergency department returns were examined. To account for global budget revenue’s six-month transition period, two difference-in-differences comparisons were performed: (1) Global budget revenue transition vs. pre-intervention, and (2) post-global budget revenue adoption vs. pre-intervention. All regressions included adjustment for baseline time trends and hospital fixed effects. emergency department return measures also included adjustment for patient and community characteristics in the regressions.
Results The final study sample included 41,965,280 emergency department encounters across the two study states. Maryland emergency department visit rates had a statistically significant decline compared to New York, with 4.6 fewer visits per 1,000 population (95% Confident Interval: -7.7, -1.5). There was a significant decline in emergency department returns rates in Maryland compared to New York, both at 72-hours, -0.7% (95% Confident Interval: -0.9%, -0.4%), and 9-days, -0.7% (-1.0%, -0.3%) after full global budget revenue implementation. Rates of admission among emergency department returns also declined, both among 72-hour (-1.8%, 95% Confidence Interval: -2.3%, -1.4%) and 9-day (-1.5%, 95% Confidence Interval: -1.8%, -1.1%) returns. While rates of intensive care unit stays among emergency department returns remained stable, and mortality among emergency department returns slightly decreased for both Maryland and New York, with a larger decline in mortality in New York compared to Maryland.
Impact Implementation of global budget revenue has led to a statewide decline in all-payer emergency department visit rates in Maryland. It also led to a decline in emergency department return rates compared to matched controls. There were no signs of increased morbidity among emergency department returns, with intensive care unit stays and mortality among returns for the most part remaining unchanged relative to controls and admissions among returns declining.
Funding Agency Emergency Medicine Foundation
Impact Statement This study indicates that the implementation of the global budget revenue population-based payment model can improve health systems by reducing all-payer avoidable emergency department utilization. Also, the results in emergency department returns suggest advancements in emergency department quality and/or care transitions under the global budget revenue model. Further research is needed to examine emergency department care delivery strategies that may explain the study’s findings.

This study examined the effects of global budgeting on ambulance diversion hours as a measure of stress on emergency care capacity.

Background In 2014, Maryland implemented a “global budget revenue” model, an innovative statewide reform that replaced fee-for-service hospital payments with a population-based payment model in which hospitals have a fixed revenue target, independent of patient volume or services provided. Prior research has demonstrated a shift towards reduced hospitalizations with global budget revenue adoption. This has increased pressure on emergency departments to find alternatives to hospital admission for patients who may have otherwise been previously admitted, which may have implications on emergency department overcrowding and patient access to emergency care.
Approach/Methods A retrospective study of statewide hospital-level diversion data from January 1, 2012 to December 31, 2017 was conducted. For Maryland hospitals, data came from the Maryland Institute for Emergency Medical Services Systems (MIEMMS). We matched Maryland hospitals with comparison hospitals from California where similar data on ambulance diversion are available through the Office of Statewide Health Planning and Development (OSHPD). Matching was based on hospital characteristics and county-level ambulance diversion policies. We conducted difference-in-differences analyses and calculated risk-adjusted quarterly diversion hours for Maryland hospitals and California hospitals by hospital in each state. Researchers at the center estimated difference-in-differences models on the log scale to account for skewness and transformed results as the ratio of ratios. Models included hospital and year fixed effects and market characteristics (primary care clinician concentration, uninsured rate, per capita income) as covariates, with clustering of standard errors on the hospital level. Summary statistics of factors that may influence ambulance diversion, including emergency department wait times, hospital financial performance (operating margin), and hospital staffing (nurse and physician full-time equivalents) were also exampled.
Results Risk-adjusted quarterly diversion hours among Maryland hospitals increased 2 times more than its matched controls after global budget revenue, with a ratio of ratios result of 2.01 (p-value 0.04). Although there was a consistently rising trend in post-global budget revenue years, the increase in diversion was most pronounced during the third year of global budget revenue adoption (3.08, p-value 0.04). Post-global budget revenue emergency department wait times among admitted patients increased in Maryland while they decreased in California, while no substantial trend was observed among hospital financial or staffing measures.
Impact Implementation of the global budget revenue payment structure led to significant increases in ambulance diversion, which reflects an increased stress on the health system’s capacity to provide emergency care.
Funding Agency Emergency Medicine Foundation
Impact Statement The rise in ambulance diversion in the setting of global budgeting has important implications on patient access to timely emergency care, and delays in care for emergent conditions pose a risk to patient safety. The increase in post-global budget revenue diversion may be related to worsening emergency department throughput in Maryland that has arisen from an increased intensity of services and/or time for care coordination in emergency departments to reduce avoidable hospitalizations, as shown in prior work. Policymakers considering the adoption of global budgeting may want to invest in the health system’s capacity for emergency care, such as increased emergency department staffing and beds, to avert unintended consequences with diversion.

 


MedStar Institute for Quality and Safety

The MedStar Institute for Quality and Safety is a leader in the science, innovation, and discovery leading to better patient quality, experience, and safety of healthcare across the continuum of health care. Along with the MedStar Institute for Quality and Safety Patient and Family Advisors and MedStar Health partners, the institute designs, implements, and tests innovations to improve the future of health for all Americans.

Research areas of focus:

  1. Safety
  2. Diagnostic Errors
  3. Quality

Click here to view the MedStar Institute for Quality and Safety’s current and past research projects.

Investigative Team

Christine Goeschel ScD, MPA, MPS, RN, FAAN
Assistant Vice President, MedStar Institute for Quality and Safety (MIQS)
Director, Center for Improving Diagnosis in Healthcare

Kelly Smith, PhD
Senior Director, Quality and Safety Research

Haslyn Hunte, PhD
Research Scientist

Bryan Buckley, PhD
Research Scientist

 


MedStar National Center for Human Factors in Healthcare

Applying human factors to healthcare reduces medical errors and allows clinicians to deliver better care to their patients. In practice, human factors boost work processes, enhances patient safety, reduces inefficiencies and improves quality. The MedStar National Center for Human Factors in Healthcare conducts rigorous research and applies scientifically grounded principles to study and improve the interrelationship between clinicians, the equipment and processes they use and the environment in which they work with the patient as a central focus. 

Research areas of focus:

  1. Patient Safety
  2. Efficiency
  3. Quality

Click here to view the center’s current and past research projects.

Investigative Team

Raj Ratwani, PhD
Vice President of Scientific Affairs, MedStar Health Research Institute

Zachary Hettinger, MD, MS
Director of Cognitive Informatics

Kristen Miller, DrPH
Scientific Director, National Center for Human Factors in Healthcare

seth-a-krevat

Seth A. Krevat, MD, FACP
Senior Medical Director and
Assistant Vice President

Sadaf Kazi, PhD
Research Scientist

Allan Fong, MS
Senior Research Scientist

Siddhartha Nambiar, PhD
Research Fellow

Long La, PharmD
Research Scientist

   

Jessica Howe, MA
Research Scientist

 

 

Contact Information

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