Balancing Efficiency and Access: Discouraging Emergency Department Boarding in a Global Budget System

Reducing cost without sacrificing quality of patient care is an important yet challenging goal for healthcare professionals and policymakers alike. This challenge is at the forefront in the United States, where per capita healthcare costs are much higher than in similar countries around the world. The state of Maryland is unique in the hospital financing landscape due to its “capitation” payment system (also known as “global budget”), in which revenue for hospital-based services is set at the beginning of the year. Although Maryland’s system has yielded many benefits, including reduced Medicare spending, it also has had unintentional adverse consequences. These consequences, such as increased emergency department boarding and ambulance diversion, constrain Maryland hospitals’ ability to fulfill their role as emergency care providers and act as a safety net for vulnerable patient populations. In this article, we suggest policy remedies to mitigate the unintended consequences of Maryland’s model that should also prove instructive for a variety of emerging alternative payment mechanisms.

High-level Emergency Care Centers and Hospitals with Both Medical/Surgical and Psychiatric Inpatient Beds are associated with a lower rate of difficulty in hospital acceptance and shorter prehospital transfer time for patients seeking care after self-harm behavior

Ambulance diversion has a significant impact on patient care outcomes. Self-harm behavior in particular is associated with difficulty in hospital acceptance. This is a retrospective observational study using the Japanese ambulance dispatch data in 2015. This study aims to determine if high-level emergency care centers and hospitals with both medical/surgical and psychiatric inpatient beds are associated with a decreased rate of difficulty in hospital acceptance and shorter prehospital transfer times for patients seeking medical care after self-harm behavior using 2015 Japanese ambulance dispatch database. Multivariable analyses were performed for difficulty in hospital acceptance and prehospital transfer time. Covariates such as age, gender, the population density, time, and severity, were included in the analysis, in addition to the presence of high-level emergency care centers and hospitals with both medical/surgical and psychiatric inpatient beds in the city. There was an association between decreased difficulty in hospital acceptance and the presence of high-level emergency care centers (Odds ratio 0.62, 95% Confidence Interval 0.55 to 0.70, P < 0.01) and hospitals with both medical/surgical and psychiatric inpatient beds (OR = 0.49, 95%CI, 0.37 to 0.65, P < 0.01). There was significant reduction in prehospital transfer time in the city with high-level emergency care centers (4.21 min, 95%CI 3.53 to 4.89, P < 0.01) and hospitals with medical/surgical and psychiatric inpatient beds (3.46 min, 95%CI 2.15 to 4.77, P < 0.01). High-level emergency care centers and hospitals with both medical/surgical and psychiatric inpatient beds were associated with significant decrease in difficulty in hospital acceptance and shorter prehospital transfer time. (The graphical abstract is shown in Fig. 1.)

Emergency medicine in Japan: past, present, and future

Quite a few changes and challenges have arisen in society in general as technology has advanced and the aging population has increased. These can lead to the recognition of the shortcomings of a society’s traditional systems and the various changes that are needed, especially in providing emergency medical care. A super-aged society has been developing in Japan, and the emergency care system needs to change according to these new demographics and society’s needs. The focus has been shifting from critical care and trauma to medical and surgical conditions involving the elderly. Challenges in triage, ambulance diversion, and staffing are discussed in this review. Possible solutions currently underway, such as a public helpline, smartphone app system, coordination by designated hospitals, and universal coverage/government support, are discussed as future directions. Emergency medicine in Japan needs to develop in a more flexible way to meet the upcoming robust challenges of the changing demographics.

Centralized Ambulance Diversion Policy Using Rolling-Horizon Optimization Framework to Minimize Patient Tardiness

Ambulance diversion (AD) is a common method for reducing crowdedness of emergency departments by diverting ambulance-transported patients to a neighboring hospital. In a multi-hospital system, the AD of one hospital increases the neighboring hospital’s congestion. This should be carefully considered for minimizing patients’ tardiness in the entire multi-hospital system. Therefore, this paper proposes a centralized AD policy based on a rolling-horizon optimization framework. It is an iterative methodology for coping with uncertainty, which first solves the centralized optimization model formulated as a mixed-integer linear programming model at each discretized time, and then moves forward for the time interval reflecting the realized uncertainty. Furthermore, the decentralized optimization, decentralized priority, and No-AD models are presented for practical application, which can also show the impact of using the following three factors: centralization, mathematical model, and AD strategy. The numerical experiments conducted based on the historical data of Seoul, South Korea, for 2017, show that the centralized AD policy outperforms the other three policies by 30%, 37%, and 44%, respectively, and that all three factors contribute to reducing patients’ tardiness. The proposed policy yields an efficient centralized AD management strategy, which can improve the local healthcare system with active coordination between hospitals.