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The ED’s Expanding Role in Hospital Admissions

Although research has focused heavily on increased use of EDs, little attention has been paid to the changing role that these facilities play in the entire healthcare system. In a study published in the New England Journal of Medicine, Arjun Venkatesh, MD, MBA, and I examined the proportion of hospital admissions that came through the ED to determine trends in general use and to confirm the experiences of emergency physicians and hospital administrators in these situations. ED Admissions on the Rise Focusing on the 13 conditions for which patients are most commonly admitted to the hospital, our analysis revealed that hospital admissions increased by 15.0%, rising from 34.3 million in 1993 to 39.5 million in 2006, but admissions from the ED increased by 50.4% (rising from 11.5 million to 17.3 million) during that same timeframe. The proportion of all inpatient stays that came through the ED increased significantly, rising from 33.5% to 43.8%. Only one of the 13 conditions studied in our analysis—coronary atherosclerosis— had a proportion that didn’t increase. More and more patients are being evaluated for coronary atherosclerosis in the ED and not admitted thanks to newer rapid “rule-out” protocols and ED-based chest-pain observation units. Our observation that more admissions are coming through the ED is likely due to several factors, most notably the advancing diagnostic and treatment capabilities of EDs and the convenience that EDs offer. As rapid and accurate diagnoses and treatments become standard, evaluating symptoms like chest pain and shortness of breath have become de facto reasons for ED referral. It has also become more difficult for outpatient providers to admit people directly to...

Making the Case for Early Palliative Care

Throughout the United States, palliative care (PC) is becoming a more established and integral component of comprehensive cancer care for patients with advanced disease. “Published research has shown that PC is associated with better quality of life and mood, improved symptom control, and more appropriate health resource use,” explains Jennifer S. Temel, MD. “It has also been linked to increased patient and caregiver satisfaction, healthcare savings, and survival.” Clinical guidelines recommend that all patients with metastatic cancer be offered PC services early in the course of the disease. Currently, many cancer centers have some form of PC services, such as inpatient consultative services and acute inpatient units. PC clinics, on the other hand, are scarcer entities. Recent analyses have suggested that integrating PC early in the ambulatory care setting is feasible and can improve patient-reported outcomes as well as several key measures of quality end-of-life care and resource use. Early integration of PC with cancer care improves patients’ understanding of their disease and prognosis, leads to more timely transitions to hospice care, and decreases chemotherapy use near the end of life. Looking Closer at Early Palliative Care According to Dr. Temel, more information about the nature and elements of early PC in ambulatory care is needed. “The integration of PC with standard oncologic care may have a different emphasis and focus than traditional inpatient or consultative PC,” she says. Earlier and longer collaborative relationships between PC clinicians and patients may allow the time and opportunity to face complex issues like treatment decisions and advanced care planning rather than focus mostly on acute symptom management and imminent death. A study...
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