[Federal Register Volume 78, Number 166 (Tuesday, August 27, 2013)]
[Notices]
[Pages 52925-52927]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-20825]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Agency for Healthcare Research and Quality
Agency Information Collection
Activities: Proposed Collection; Comment Request.
AGENCY: Agency for Healthcare Research and Quality, HHS.
ACTION: Notice.
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SUMMARY: This notice announces the intention of the Agency for
Healthcare Research and Quality (AHRQ) to request that the Office of
Management and Budget (OMB) approve the proposed information collection
project: ``Pilot Test of an Emergency Department Discharge Tool.'' In
accordance with the Paperwork Reduction Act of 1995, 44 U.S.C.
3506(c)(2)(A), AHRQ invites the public to comment on this proposed
information collection.
DATES: Comments on this notice must be received by October 28, 2013.
ADDRESSES: Written comments should be submitted to: Doris Lefkowitz,
Reports Clearance Officer, AHRQ, by email at
[email protected].
Copies of the proposed collection plans, data collection
instruments, and specific details on the estimated burden can be
obtained from the AHRQ Reports Clearance Officer.
FOR FURTHER INFORMATION CONTACT: Doris Lefkowitz, AHRQ Reports
Clearance Officer, (301) 427-1477, or by email at
[email protected].
SUPPLEMENTARY INFORMATION:
Proposed Project
Pilot Test of an Emergency Department Discharge Tool
The research study ``Pilot Test of an Emergency Discharge Tool''
fully supports AHRQ's mission. The ultimate aim of this study is to
pilot test a discharge tool which has the potential to reduce
unnecessary visits to the Emergency Department (ED), reduce healthcare
expenditure in the ED, as well as streamline and enhance the quality of
care delivered to ED patients.
The ED is an important and frequently used setting of care for a
large part of the U.S. population. In 2006, there were nearly 120
million ED visits in the U.S., of which only 15.5 million (14.7%)
resulted in admission to the hospital or transfer to another hospital.
Thus the majority ED visits result in discharge to home. Patients
discharged from the ED face significant risk for adverse outcomes, with
between 3-5 patients per 100,000 visits experiencing an unexpected
death following discharge from the ED. Additionally, a sizable minority
of patients return to the ED frequently. Published studies estimate
that 4.5% to 8% of patients revisit the ED 4 or more times per year,
accounting for 21% to 28% of all ED visits. Internal data from John
Hopkins Hospital, AHRQ's contractor for this pilot test, supports these
findings with 7% of their patients accounting for 26% of visits to the
Johns Hopkins Hospital ED in 2011.
Patients who revisit the ED contribute to overcrowding, unnecessary
delays in care, dissatisfaction, and avoidable patient harm. ED
revisits are also an important contributor to rising health care costs,
as ED care is estimated to cost two to five times as much as the same
treatment delivered by a primary care physician. Thus it is estimated
that eliminating revisits and inappropriate use of EDs could reduce
health care spending as much as $32 billion each year. Overall, an
effective and efficient ED discharge process would improve the quality
of patient care in the ED as well as reduce healthcare costs.
To respond to the challenges faced by our nation's EDs and the
patients they serve, AHRQ will develop and pilot test a tool to improve
the ED discharge process. More specifically, this project has the
following goals:
(1) Develop and Pilot Test a Prototype ED Discharge Tool in a
limited
number of settings to assess:
(A) The feasibility for use with patients;
(B) The methodological and resource requirements associated with
tool use;
(C) The feasibility of measuring outcomes;
(D) The costs of implementation and;
(E) Treliminary outcomes or impacts of tool use.
(2) Revise the Tool based on the results from the Pilot Test
This study is being conducted by AHRQ through its contractor, John
Hopkins Hospital, pursuant to AHRQ's statutory authority to conduct and
support research on healthcare and on
[[Page 52926]]
systems for the delivery of such care, including activities with
respect to the quality, effectiveness, efficiency, appropriateness and
value of healthcare services and with respect to quality measurement
and improvement. 42 U.S.C. 299a(a)(1) and (2).
Method of Collection
To achieve these goals the following data collections will be
implemented:
(1) Emergency Department Discharge Tool (EDT)--The EDT will be
pilot tested in the three John Hopkins EDs in Baltimore. The purpose of
the EDT is to assist hospitals in identifying patients who excessively
use the ED and can be categorized as ``frequent ED users,'' and to
target interventions to these patients to reduce the risk of further
avoidable revisits. A designated ED personnel will screen the medical
record of all adult patients for the presence of frequent ED use, the
key risk factor for ED discharge failure. Frequent ED use is defined
as: (1) 1 or more previous ED visit within the last 72-hours, or (2) 2
or more previous ED visits within the last 3 months, or (3) 3 or more
ED visits within the last 12 months. This definition can be modified to
align with the resources of the individual ED.
For those flagged as frequent ED users this tool uses data
collected from the patient's record and from the patient himself to
identify individuals with risk factors that have been shown in the
literature to predict sub-optimal ED discharges and resulting revisits.
These risk factors include patients who are uninsured, lack a primary
care physician, have psychiatric diseases, are substance users, have
difficulty caring for themselves, or have trouble comprehending ED
discharge instructions.
A user's manual (EDT User's Manual) is also provided to assist EDs
in developing resources to provide interventions recommended by the
EDT. No data collection activities will be made from this manual.
(2) One Month Patient Follow-up--After the ED visit, a project
research assistant (RA) will have a follow-up telephone interview with
all enrolled patients. During the interview, the RA will inquire about
the patient's remembrance of the instructions that were given for the
patient.
(3) Three Month Patient Follow-up--Patients who are uninsured will
receive an additional phone call 3 months after the ED visit to assess
whether or not they were able to acquire insurance.
(4) Post Pilot Test Focus Groups--AHRQ will conduct three sets of
focus groups to collect qualitative data about the usability and
usefulness of the EDT from three stakeholder groups: EDT implementers,
patients, and post-ED care providers. Questions for each of the focus
groups will vary based on their differing objectives:
(A) EDT Implementers Focus Group--For implementers of the EDT (RNs,
case managers, social workers, research assistants), the objectives
will include: (1) How well it does or does not meet implementer goals
of discharge; (2) resources required for implementation; and (3)
unintended consequences or impacts on other ED operations.
(B) Patient Focus Group--For the patients, the objective will be:
(1) What was their general impression of the EDT; (2) did the EDT
improve the ED discharge process for them; and (3) do they foresee any
potential unintended problems of the EDT.
(C) Post-ED Care Providers Focus Group--For the post-ED care
providers, the objectives are to determine: (1) How well the EDT has
met the needs of these providers in caring for these patients; (2) how
feasible it has been to properly care for patients for whom the EDT had
been implemented; (3) if there are any unintended consequences of using
the EDT. Post-ED care provider focus group members will be drawn from
Johns Hopkins Community Physicians, East-Baltimore Medical Center (a
primary referral site for patients without primary care), and
Healthcare for the Homeless, a not-for-profit organization in
Baltimore, Maryland that provides health services, education and
advocacy to people affected by homelessness.
(5) Post Pilot Test In-depth Interviews--AHRQ will conduct semi-
structured interviews with approximately eight individuals from each of
the 3 stakeholder groups: EDT implementers, patients, and post-ED care
providers. These individuals will provide feedback on issues surfaced
during the focus groups. This will provide an opportunity to delve more
deeply into specific topics of interest.
(6) Administrative and Observational Data--Quantitative outcome
measures will come from an extraction of medical record data and direct
observations performed by project RAs. Data will be extracted from
hospital billing records and Electronic Medical Records (EMRs) and will
include frequency of revisits, cost of 72-hour returns, cost of ED
visits per 3 months and the cost of implementing the EDT. To calculate
costs of program implementation, RAs will observe the time required by
social work, case management, and nursing staff to implement the
interventions prescribed in the tool. They will also keep a log of the
materials given to the patients as part of the intervention. To
evaluate the percentage of patients evaluated for assistance or
placement, RAs will observe case managers/social workers during their
interaction with the patients. To evaluate the percentage of follow-up
phone calls, the RAs will keep a log of attempts and actual contacts.
Since these data collections involve RA observations, or extractions
from existing medical records performed by the RA, they pose no burden
to the hospital or public and therefore are not included in the burden
estimates in Exhibit 1.
Estimated Annual Respondent Burden
Exhibit 1 shows the estimated annualized burden for the
respondents' time to participate in this pilot test. The EDT will be
pilot tested with a total of 1,200 patients (50 per week * 8 weeks * 3
sites = 1,200) and takes about 20 minutes per patient to complete. The
one-month patient follow-up will be conducted with all 1,200 patients
and will take 10 minutes to complete. The 3-month patient follow-up
will be conducted with those patients identified as being uninsured and
is estimated to take 5 minutes to complete.
Focus groups will be conducted with all three of the stakeholder
groups (EDT implementers, patients, and post-ED care providers). There
will be two groups held for the EDT implementers consisting of 8
persons each (16 total), and one group of 8 for both the patients and
the post-ED care providers. Each focus group will last for 2 hours.
As a follow-up to the focus groups in-depth interviews will be
conducted with eight members from each of the three stakeholder groups.
The interviews will require one hour to complete. The total annualized
burden is estimated to be 708 hours.
Exhibit 2 shows the annualized cost burden associated with the
respondents' time to participate in the pilot test. The total
annualized cost burden is estimated to be $16,359.
[[Page 52927]]
Exhibit 1--Estimated Annualized Burden Hours
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Number of
Number of responses Hours per Total
Form name respondents per response burden
respondent hours
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Pilot Test of the Emergency Department Discharge Tool (EDT)
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EDT..................................................... 1,200 1 20/60 400
One Month Patient Follow-up............................. 1,200 1 10/60 200
Three Month Patient Follow-up........................... 240 1 5/60 20
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Post Pilot Test Focus Groups and Interviews
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EDT Implementers Focus Group............................ 16 1 2 32
Patient Focus Group..................................... 8 1 2 16
Post-ED Care Providers Focus Group...................... 8 1 2 16
EDT Implementer Interview............................... 8 1 1 8
Patient Interview....................................... 8 1 1 8
Post-ED Care Providers Interview........................ 8 1 1 8
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Total............................................... 2,696 na na 708
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Exhibit 2--Estimated Annualized Cost Burden
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Average
Form name Number of Total hourly wage Total cost
respondents burden hours rate\*\ burden hours
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Pilot Test of the Emergency Department Discharge Tool (EDT)
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EDT..................................................... 1,200 400 $22.01\a\ $8,804
One Month Patient Follow-up............................. 1,200 200 22.01\a\ 4,402
Three Month Patient Follow-up........................... 240 20 22.01\a\ 440
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Post Pilot Test Focus Groups and Interviews
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EDT Implementers Focus Group............................ 16 32 27.42\b\ 877
Patient Focus Group..................................... 8 16 22.01\a\ 352
Post-ED Care Providers Focus Group...................... 8 16 45.36\c\ 726
EDT Implementer Interview............................... 8 8 27.42\b\ 219
Patient Interview....................................... 8 8 22.01\a\ 176
Post-ED Care Providers Interview........................ 8 8 45.36\c\ 363
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Total............................................... 2,696 708 na 16,359
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\*\National Compensation Survey: Occupational wages in the United States May 2012, ``U.S. Department of Labor,
Bureau of Labor Statistics.''
\a\--based on the mean wages for All Occupations (00-0000)
\b\--salary based upon average of: 2 nurses (29-1141), 2 case managers (29-1141), 2 social workers (21-1022),
and 2 research assistants (19-4061)
\c\--salary based upon average of: 2 physicians (29-1060), 2 nurses (29-1141), 2 case managers (29-1141), 2
social workers (21-1022).
Request for Comments
In accordance with the above-cited Paperwork Reduction Act
legislation, comments on AHRQ's information collection are requested
with regard to any of the following: (a) Whether the proposed
collection of information is necessary for the proper performance of
AHRQ health care research, quality improvement and information
dissemination functions, including whether the information will have
practical utility; (b) the accuracy of AHRQ's estimate of burden
(including hours and costs) of the proposed collection(s) of
information; (c) ways to enhance the quality, utility, and clarity of
the information to be collected; and (d) ways to minimize the burden of
the collection of information upon the respondents, including the use
of automated collection techniques or other forms of information
technology.
Comments submitted in response to this notice will be summarized
and included in the Agency's subsequent request for OMB approval of the
proposed information collection. All comments will become a matter of
public record.
Dated: August 8, 2013.
Carolyn M. Clancy,
Director.
[FR Doc. 2013-20825 Filed 8-26-13; 8:45 am]
BILLING CODE 4160-90-M