Academic Emergency Medicine最新文献

Background: The US is experiencing an epidemic of opioid misuse and mortality. Effective treatments are available, including medications for opioid use disorders (MOUD), but they are greatly underused due to a variety of barriers. In response, some US hospitals have established programs to identify emergency department (ED) patients with opioid use disorders (OUD) and begin treatment with MOUD ("ED induction"). For this model to be widely adopted, financial sustainability for hospitals is critical. Little is known about the financial aspects of ED-based treatment models, including insurance billing and reimbursement.

Objectives: Our study addressed the following questions about ED-based induction of OUD treatment: (1) Which components of this model are billable to insurers? (2) How do hospitals fund the components that are not billable? (3) Does ED-based induction generate savings that could help fund that service?

Methods: We conducted a qualitative study, involving semi-structured interviews with officials at selected US hospitals. Potential interviewees were identified using a snowball sampling approach. We conducted 12 interviews across 10 states, mostly with urban teaching hospitals.

Results: Key findings include, (1) medication costs are often billable to insurers, but costs of key para-professional staff like peer navigators are not, requiring the hospital to absorb their salaries. Even some billable costs are reimbursed at low rates which challenge sustainability. (2) To fund non-billable components, hospitals typically rely on time-limited grant funding, including the federal 340B drug rebate program. (3) Several interviewees anticipated cost savings to their hospitals from reduced use of ED services by patients who had no (or low-paying) insurance.

Discussion: These findings indicate that some hospitals are able to sustain ED-based induction of MOUD using time-limited grant funding. However, wider dissemination of this model will likely require more stable funding streams, such as Medicaid reimbursement, paying adequate rates, and coverage of personnel.

Background: Alcohol withdrawal syndrome (AWS) significantly contributes to ED resource utilization. While phenobarbital is increasingly used as an alternative to benzodiazepines, data comparing their impact on ED utilization remain limited. We evaluated whether phenobarbital monotherapy improves ED operational outcomes compared to benzodiazepines or combination therapy.

Methods: We conducted a single-center, retrospective cohort study of 1178 adults at a regional academic medical center from January 1, 2020, to December 31, 2023. Patients ≥ 18 years old who were treated with intravenous (IV) phenobarbital, IV benzodiazepines, or both for AWS in the ED were included. The primary outcome was hospital admission. Secondary outcomes included ED length of stay, return visits within 72 h of index visit, and 30-day hospital readmission. A formalized data abstraction process was utilized. Analyses used chi-squared or Kruskal-Wallis tests and logistic regression to estimate odds ratios with 95% confidence intervals.

Results: Of 777 eligible encounters, 459 (59.1%) resulted in admission. Admission rates were 74.0% for benzodiazepine-only encounters, followed by combination therapy (62.4%), and lowest for phenobarbital-only (52.1%; OR 0.44, 95% CI 0.30-0.66, p < 0.0001). Among discharged patients (318 encounters), median ED LOS was shortest in the phenobarbital-only group (5.8 h), versus 7.6 h for benzodiazepine-only and 10.3 h for combination therapy (p < 0.0001). Logistic regression analysis revealed treatment with phenobarbital alone was independently associated with discharge, while increasing age, increasing heart rate, and treatment with benzodiazepines alone were independently associated with hospitalization.

Conclusions: Phenobarbital monotherapy for AWS was associated with lower admission rates, shorter ED LOS, and fewer IV medication administrations compared to benzodiazepine-based regimens. Return visit rates were similar across all groups. These findings are exploratory, underscoring the need for prospective studies to confirm these associations.

Background: The "minority tax", also known as the "diversity tax" refers to the additional burden placed on minoritized individuals in advancing diversity, equity, and inclusion (DEI). Although DEI efforts have evolved over time, evidence on its emotional, professional, and institutional impacts in academic emergency medicine (EM) is limited. We examined the various impacts of the minority tax in this population.

Methods: We conducted a qualitative study using a descriptive phenomenological framework to explore the lived experiences of 21 academic EM faculty leaders engaged in DEI work. Participants were purposively sampled across U.S. regions. Semi-structured interviews were conducted (March-May 2023), transcribed, and analyzed using thematic analysis informed by both inductive and deductive coding strategies. We explored personal and professional impacts of DEI engagement, experiences with the minority tax, and strategies for mitigation.

Results: Participants described their DEI roles as a "double-edged sword," balancing meaningful engagement with substantial emotional and professional costs. Sixteen of 21 participants identified direct experiences with the minority tax, including expectations to serve as cultural representatives, provide uncompensated labor, and experiences of institutional marginalization. Despite these challenges, many participants found personal fulfillment in their work and emphasized mentorship as both a key source of support and a driver of career advancement. Suggested strategies for addressing the minority tax included stronger institutional support, appropriate compensation for DEI contributions, and equitable distribution of DEI responsibilities across all faculty, regardless of identity.

Conclusions: The minority tax in academic emergency medicine presents a complex challenge that carries significant emotional and professional costs even as DEI work can provide personal meaning and career advancement. Addressing this burden requires systemic changes, including recognition of DEI efforts in career progression and shared responsibility across all faculty demographics.

Introduction: Emergency medical services (EMS) providers are often first responders to agitated older adults, providing critical clinical care and transport. However, significant knowledge gaps persist in our understanding of agitation management for older adults in the prehospital setting.

Aims: To describe the barriers and facilitators to the management of agitation in older adults and the reduction of restraint use by EMS providers.

Methods: In-depth semi-structured qualitative interviews (n = 30) took place with EMS providers employed in Alberta, Canada. The theoretical domains framework (TDF) served as a guiding structure for the development of the interview guide. Framework analysis was used to analyze the qualitative data: a line-by-line thematic analysis was used to identify codes/themes, which were then mapped onto the TDF, and behavior change wheel.

Results: Six major thematic categories were identified. EMS providers reported inadequate training and support, especially for managing agitation in older adult populations. Restraints are used as a safety measure for patient and provider safety, and as a last resort once other agitation management strategies have been exhausted. EMS providers report a complex decision-making matrix of balancing the risks, benefits, and ethical considerations of restraint use, which is often collaborative and integrates EMS protocols. Common barriers to effective agitation management in EMS, as well as non-restraint agitation management techniques are also discussed.

Conclusion: The present study is the first in-depth exploration of EMS provider experiences regarding the management of agitation and chemical and physical restraints in older adults.

Objective: Cluster-randomized trials (also called group-randomized trials) are increasingly common in emergency care research. In such trials, groups of participants are allocated to different interventions based on naturally occurring "clusters," such as clinics, hospitals, or emergency medical services agencies. In this methodological review, we introduced key terminology and features of cluster-randomized trials, described common rationales for cluster-randomization and its most common limitations, and offered brief advice for conducting and critically appraising cluster-randomized trials in emergency care research.

Results: Researchers elect to use cluster-randomization when individual participant randomization is not preferred or not possible. Common reasons include a desire to limit contamination between study groups, logistical convenience relating to trial administration or study procedures, or the use of an intervention that is naturally group-oriented, such as an educational intervention or clinical decision support tool that is directed toward influencing clinician behaviors. Although cluster-randomization has advantages in these contexts, this approach also comes with some notable weaknesses, such as inflated sample size requirements, greater difficulty in blinding participants and researchers, and an increased risk of baseline imbalances between comparator groups. When reading and critically appraising cluster-randomized trials, emergency clinicians should consider whether researchers have appropriately justified group over individual randomization, accounted for different levels of clustering and the degree of correlation between participants within clusters (intracluster correlation), and appropriately consented various levels of participants to study participation.

Conclusions: Cluster-randomized trials are frequently used in emergency care research, especially as researchers are increasingly evaluating educational or electronic health record interventions that are naturally group-oriented or have a high risk of contamination. After reading this review, emergency medicine clinicians and researchers will have a foundational understanding of key cluster trial features and will be able to assess the quality and limitations of emerging evidence.

Study objective: To report on first-job compensation packages and negotiation practices among a sample of recent emergency medicine (EM) research fellowship graduates, describe gender differences in negotiation behaviors, and explore perceived barriers and facilitators to early research career success.

Methods: We conducted a national qualitative study using semi-structured interviews with EM research fellowship graduates from 2019 to 2023. Participants were recruited via the Society for Academic Emergency Medicine and National Clinician Scholars Program fellowship directories and alumni networks. Interviews focused on participants' first academic job search post-fellowship and were analyzed using thematic analysis with an inductive and deductive coding approach. Themes were developed through consensus coding and interviews continued until thematic saturation was reached.

Results: Seventeen participants completed interviews of 30-60 min in duration; 53% were women, 53% identified as white, and 59% had a first job in the Northeast. Most received one to two job offers and reported varied start-up packages, clinical hours, and non-clinical effort. A majority (59%) did not negotiate their job offers. Participants cited lack of transparency about compensation and institutional expectations as the primary barrier to negotiation. Mentorship-particularly from senior researchers-was described as a key facilitator of early-career success and a major factor influencing job acceptance decisions. Negotiation, when it occurred, more commonly focused on non-clinical effort than salary or start-up funding. Participants emphasized that increased research effort and mentorship were essential to productivity and career sustainability.

Conclusion: Most EM fellowship graduates did not negotiate key elements of their first academic job offer, often due to a lack of accessible information. Mentorship and protected time for research were the two biggest drivers of job acceptance and perceived productivity. Greater transparency and standardized employment offers-or formal negotiation training in the absence of the latter-may help build a more productive and sustainable pipeline of EM physician-scientists.