[Federal Register Volume 79, Number 19 (Wednesday, January 29, 2014)]
[Notices]
[Pages 4718-4721]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-01709]
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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.
This proposed information collection was previously published in
the Federal Register on August 27th, 2013 and allowed 60 days for
public comment. One comment was received. The purpose of this notice is
to allow an additional 30 days for public comment.
DATES: Comments on this notice must be received by February 28, 2014.
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) Preliminary 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 systems for the delivery of such
care, including activities with respect to the
[[Page 4719]]
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) Pilot Test of the 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,'' as well as to target interventions to these
patients to reduce the risk of further avoidable revisits. A research
assistant 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) 3 or more previous ED visits within
the last 3 months, or (3) 4 or more ED visits within the last 12
months. This definition can be modified to align with the resources of
the individual ED.
This tool uses data collected from the record of patients that are
flagged as frequent ED users. By asking patients a series of questions
about their medical history, the tool also helps 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 being uninsured, lack of a primary care physician,
having psychiatric diseases, abusing substances, difficulty caring for
oneself, or having trouble comprehending ED discharge instructions.
A User's Guide (EDT User's Guide) is also provided to assist EDs in
developing resources to provide interventions recommended by the EDT.
No data collection activities will occur from this manual.
(2) One Month Patient Follow-up Telephone Interview--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 success of the interventions that were
given for the patient.
(3) Three Month Patient Follow-up Telephone Interview--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) Implementer Focus Groups--AHRQ will conduct four sets of focus
groups to collect qualitative data about the usability and usefulness
of the EDT from four stakeholder groups: Three groups of EDT
implementers and one group of research assistants. Questions for each
of the focus groups will vary based on their differing objectives:
(a) EDT Implementers Focus Group (non-RA)--For non-RA implementers
of the EDT (RNs, case managers, social workers,), the objectives will
include exploring: (1) How well it does or does not meet implementer
goals of discharge; (2) experiences with rollout and implementation,
including resources required for implementation; (3) impressions of the
value, strengths and weaknesses of the EDT; and (4) unintended
consequences or impacts on other ED operations. The focus groups will
consist of 8 implementers. Three focus groups will be conducted, one
for each pilot site.
(b) Research Assistant Focus Group--The three research assistants
who will be implementing the EDT will participate in one focus group in
which they discuss: (1) Experiences with implementation (including
comparisons in their experiences across the three test sites; (2)
possible areas for improvement; (3) unintended consequences or impacts
on other ED operations.
(5) Key Informant Interviews--AHRQ will conduct semi-structured
interviews with no more than twenty-four individuals that can be
classified as either ED Directors, patients, or community 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. The interview guides are
included as for patients, for community care providers, and for ED
Directors.
(a) Patient Interviews--For the patients, the objective will be to
explore: (1) The barriers they face in obtaining health care; (2) their
experiences in the ED in visits prior to, and after, implementation of
the EDT (3) their satisfaction with the care they received in the ED
and their remaining unmet needs. Fifteen patients will be interviewed
individually.
(b) Community Care Providers Interviews--For the post-ED care
providers, the objectives are to explore challenges in communication
and coordination for patients referred to them by the ED and the degree
to which the EDT can address those challenges. 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.
Six community care providers will be interviewed for this section.
(c) ED Directors Interviews--Interviews from ED Directors will
occur to get their opinions of the EDT from their perspectives as the
ultimate orchestrators of processes in the emergency room and decision-
makers regarding operations (resources use, staffing). Three ED
directors will be interviewed separately for this portion.
(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, they pose no burden to the hospital or
public and therefore are not included in the burden estimates in
Exhibits 1 and 2 below.
No pre-intervention measures will be collected because this is a
feasibility study to evaluate the methodology and feasibility of
collection of this data.
Estimated Annual Respondent Burden
Exhibit 1 shows the estimated annualized burden for the
respondents' time to participate in this pilot test. A research
assistant will use the EMR to screen patients for past frequent ED use.
This step does not represent a participant burden. Based upon
historical data at our three participating sites, we expect
approximately 200 patients per week to qualify as ``frequent users'' at
these sites. Based upon available resources and recruitment, we expect
to enroll and use the EDT with approximately 50 of these patients per
week at each site to identify their specific risk factors and tailor
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interventions to their needs. Thus we will have a total of 900 patient
participants (50 patients/per week * 6 weeks * 3 sites = 900 patients
total). It will take about 20 minutes per patient to collect the data
associated with the EDT. The one-month patient follow-up will be
conducted with all 900 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.
Four focus groups will take place among RAs and non-RA EDT
implementers. The first focus group will consist of three RAs who
implemented the discharge tool. The other three separate focus groups
will exclude RAs and include eight other ED personnel that implemented
the discharge tool. The total annualized burden for these focus groups
is estimated to be 54 hours.
As a follow-up to the focus groups, in-depth interviews will also
be conducted with members from different stakeholder groups. Between 12
and 16 patients will be interviewed as well as three ED directors and
six community healthcare providers. The interviews will be conducted in
person and require one hour to complete. The total annualized burden
for these interviews is estimated to be 30 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 $13,262.
Exhibit 1--Estimated Annualized Burden Hours
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Number of
Form name Number of responses per Hours per Total burden
respondents respondent response hours
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Pilot Test of the Emergency Department Discharge Tool (EDT)
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EDT............................................. 900 1 20/60 300
One Month Patient Follow-up..................... 900 1 10/60 150
Three Month Patient Follow-up................... 180 1 5/60 15
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Implementer Focus Groups
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RA Focus Group.................................. 3 1 2 6
EDT Implementer (non-RA) 1 Focus Group. 8 1 2 16
EDT Implementer (non-RA) 2 Focus Group. 8 1 2 16
EDT Implementer (non-RA) 3 Focus Group. 8 1 2 16
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Key Informant Interviews
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Community Healthcare Provider Interview......... 6 1 2 12
Patient Interview............................... 15 1 1 15
ED Director Interview........................... 3 1 1 3
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Total....................................... 2,031 NA NA 549
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Exhibit 2--Estimated Annualized Cost Burden
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Number of Total burden Average hourly Total cost
Form name respondents hours wage rate* burden
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Pilot Test of the Emergency Department Discharge Tool (EDT)
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EDT............................................. 900 300 \a\ $22.01 $6,603
One Month Patient Follow-up..................... 900 150 \a\ 22.01 3,302
Three Month Patient Follow-up................... 180 15 \a\ 22.01 330
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Implementer Focus Groups
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RA Focus Group.................................. 3 6 \d\ 17.86 107
EDT Implementer (non-RA) 1 Focus Group. 8 16 \b\ 27.42 439
EDT Implementer (non-RA) 2 Focus Group. 8 16 \b\ 27.4 439
EDT Implementer (non-RA) 3 Focus Group. 8 16 \b\ 27.42 439
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Key Informant Interviews
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Community Healthcare Provider Focus Group....... 6 12 \c\ 45.36 544
Patient Interview............................... 15 15 \a\ 22.01 330
ED Director Interview........................... 3 3 \e\ 97.30 292
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Total....................................... 2,031 549 NA 12,825
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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).
\d\ based on mean hourly wage of: Social Science Research Assistants (19-4061).
\e\ based on mean annual wage of: Physicians and Surgeons (29-1060).
[[Page 4721]]
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: January 16, 2014.
Richard Kronick,
AHRQ Director.
[FR Doc. 2014-01709 Filed 1-28-14; 8:45 am]
BILLING CODE 4160-90-P