Introduction
Methods
Results
Discussion
Limitations
Conclusion

INTRODUCTION

Transfers from skilled nursing facilities (SNF) to the emergency department (ED) account for approximately 14 million ED visits annually, a fifth of which may be avoidable.¹ In many cases, ED visits lead to admission, which in turn conveys risks of cognitive and functional decline, nosocomial infections, and falls.^2,3 Furthermore, for the frailer subpopulation of SNF residents transferred to the ED, up to 78% of their resulting hospitalizations are potentially avoidable.⁴ Several solutions have been proposed to reduce admissions for these patients. One is to improve the quality of ED care for seniors and SNF residents through the development of geriatric-focused emergency care, and improved communication between SNFs and EDs.⁵ Incentive programs have also been established to improve longitudinal management of chronic medical conditions by SNFs, reducing transfers for patients with congestive heart failure (CHF) and diabetes mellitus (DM).^6,7

Few studies have targeted the scenario that often triggers a transfer: when the SNF resident has an acute medical condition such as a fall, a fever, or an exacerbation of a chronic disease. Many SNFs retain on-call medical staff, but most lack the infrastructure to manage acute unscheduled care, particularly after-hours, and SNF healthcare teams often have little recourse other than to call 911 when patients need evaluation.^8-10 One potential intervention to address this scenario is enlisting a physician via telemedicine to evaluate patients with acute care needs at the SNF. Telemedicine consults have been successfully used within EDs for a variety of subspecialties; providing rapid evaluations within the SNF setting could obviate transfers for minor injuries. Prompt evaluations could enable earlier interventions in acute infections and chronic disease exacerbations, potentially preventing the need for ED transfers or facilitating earlier transfers when warranted.

Objectives

Our primary objective was to determine whether a SNF-based telemedicine consultation service staffed by emergency physicians (EP) could reduce hospital admissions of patients requiring acute evaluation, compared to patients who were taken directly to an ED. Our secondary objectives were to compare care escalation for conditions most amenable to on-site acute care in the SNF, and to broadly examine the financial implications of on-site acute care.

METHODS

Study Setting and Design

This was a retrospective, observational study of SNF residents between January 1, 2017–January 1,2018. The intervention group comprised residents of six urban SNF facilities in the Northeastern United States, who underwent an acute telemedicine evaluation.¹¹ The telemedicine service consists of an on-demand consultation by an EP, facilitated by a clinical care specialist (CCS) who is a paramedic or emergency medical technician on-site at all times. The service is used for acute evaluations when facility staff judged that patients would otherwise require ED transfer. The CCS uses a cart with point-of-care labs, electrocardiograms, telemetry, and ultrasound (Figure 1). Patients can also be directly transported for outpatient imaging (eg, chest radiograph and computed tomography. Order sets and pathways are used to streamline decisions to treat in place or transfer. The CCS monitors SNF residents in accordance with EP orders and can re-initiate consultations. If the patient cannot be definitively managed on-site, or if the patient or family prefers transfer, the EP directs staff to carry out immediate treatments and expedite transport.

The control group consisted of residents of SNFs that did not offer telemedicine evaluations. These residents were transferred via ambulance to the ED of an urban tertiary care hospital with 55,000 visits annually. Patients were broadly matched on age and gender. The study was approved by the institutional review board of the tertiary care hospital.

Protocol

We used electronic health record (EHR) data from the telemedicine service and the tertiary care hospital to abstract age, gender, chief complaint, and disposition. Data were de-identified in accordance with the Health Insurance Portability and Accountability Act-Safe Harbor criteria.

Analysis

Our primary outcome was whether a patient was ultimately admitted to the hospital. For the intervention group, EHR data beyond the telemedicine visit was not available; hence, we could not definitively determine whether the patient was admitted after ED transfer. To address this limitation, we conservatively designated any patient in the intervention group who was transferred to the ED as admitted. This should underestimate the potential benefit of the intervention, as in the general Medicare population only about 30% of those treated in the ED are admitted as inpatients.¹² The use of a full calendar-year period was intended to avoid the potential confounding effects of seasonality. The two populations were tested for demographic concordance in terms of age using an independent t-test and gender using a Fisher’s exact test, and a logistic regression was conducted with both features relative to the outcome to examine whether they played a role as confounders.

Patients in the control group were evaluated in the ED and designated as either admitted or discharged. Patients were considered discharged from the ED if they did not have an inpatient admission, or if they were directly discharged to their original facility, discharged to acute rehab, or discharged after observation care in the ED. For our primary outcome, we report the odds ratio (OR) of admission with 95% confidence interval (CI). As a significant potential benefit of telemedical care for SNFs is early intervention in chronic disease exacerbations, we conducted a subanalysis examining the OR of admission across the three most common chronic disease-related presentations found among the study population, with strict Bonferroni correction for multiple comparisons.

RESULTS

A total of 2311 patients were evaluated in the SNF-based group, matched with 2295 patients in the control group. The groups had similar distributions by gender (intervention group: 60.2% female; control group 58.1% female; p = 0.14), but the control group was slightly older (intervention group: 75.6 [standard deviation (SD) 12.3]; control group 78.9 [SD 8.14]; p<0.001). A logistic regression demonstrated no significant association between these factors and admission. The most common reasons for telemedicine activation were exacerbations of CHF, chronic obstructive pulmonary disease (COPD), and DM (Table 1). The mean cost of the telemedicine care delivery in this study was $816 per episode.

Patients who received SNF-based acute care were less likely to have their care escalated. Only 27% of the SNF-based group were transferred to the ED, whereas 71% of the control group were admitted to the hospital from the ED (OR = 0.15 (95% CI, 0.13–0.17), p < 0.001, Table 1). These results were directionally consistent across the top three conditions, although rates of presentation for all three were significantly higher in the SNF-based group (Table 1).

DISCUSSION

Telemedicine has been heralded as a panacea to many systemic problems in healthcare; although widespread adoption continues¹³ its proven benefits are more modest. Many studies examining telemedicine across settings have failed to find compelling clinical or cost benefits,^14-16 although patients are often satisfied with these services and remain optimistic about their potential.^17,18 The most successful applications of telemedicine have been subspecialty consultations in resource-limited settings. In the ED, this includes tele-neurology for acute stroke, remote radiology,^19-23 and psychiatric evaluations.^24,25 Telemedicine has also shown promise within SNFs for chronic disease management and related hospitalizations.

A pilot study by Dy et al demonstrated that a telemedicine team of an endocrinologist, nurse, and dietician improved glycemic control for SNF residents.²⁶ Grabowski et al demonstrated a trend toward reducing unnecessary transfers by replacing SNFs’ on-call physicians with telemedicine, but had limited utilization of their service.²⁷ More recently, Gillespie et al showed telemedicine reduced ED utilization for patients with dementia in senior living communities.²⁸

The intervention evaluated in our study lies at the intersection of these trends, providing an EP as a specialty consultant. The potential to decrease ED transfer and hospital admission is facilitated by the CCS and expanded diagnostic tools, allowing the EP to conduct much of an ED workup in situ. Furthermore, the ability of the CCS to fulfill medication orders and re-initiate consultation effectively allows for observation care at the SNF.

While rigorous cost-effectiveness studies of telemedicine are lacking,^15,16,29 the complexity of the interventions in this study invariably comes at increased cost. The average cost of the telemedicine service in this study was $816 per episode, compared to the flat rate of $30,000 per facility per year charged by Grabowski et al. Amortized across 2311 consultations in six SNFs over a one-year period, this represents a more than tenfold increase. Conversely, the average Medicare payment for a SNF-based rehospitalization is over $10,000.³⁰ Considering the added expenses of ambulance transportation and EP fees, this enhanced telemedicine service would be cost-effective if it averted 10% of hospitalizations. The data from this program suggests an 80% reduction in care escalation, suggesting this is a worthwhile investment, irrespective of the clinical benefits from avoiding unnecessary admissions.

LIMITATIONS

This study has several significant limitations. It is possible that the telemedicine program was activated for conditions where the staff would not automatically initiate transport to the ED, and SNFs may have substantial differences in their threshold for transferring patients; however, a similar reduction was seen in patients with COPD and CHF exacerbations, conditions where ED transfer is typically required. The lack of follow-up information for the intervention group obscures patients’ disposition after ED transfer, which we addressed by conservatively assuming these patients were admitted when many may have been observed or discharged directly. Seasonality is also a potential confounding factor, as during flu season facilities without the capacity to test or cohort patients may be more inclined to transfer patients. Finally, as a pilot study our analysis does not include specific markers of disease severity, such as oxygen saturation during COPD and CHF exacerbations, which could substantially affect the effects of the intervention. More robust matching of the groups (eg, propensity-score matching on age and comorbid conditions) would improve the generalizability of our results.

CONCLUSION

In this pilot study, emergency physician-staffed telemedicine acute evaluations of SNF residents were associated with lower rates of hospital admissions than typical ED care, including in exacerbations of chronic diseases such as COPD and CHF, which represented a substantial portion of overall evaluations in the intervention group. The COVID-19 pandemic has broadly increased the tempo and urgency of telemedicine use; however, more in-depth studies are needed to determine whether these interventions result in longer-term reductions in chronic disease exacerbations and hospitalization rates among SNF residents. While comprehensive cost data for admitted patients was not available in this study, the reduced likelihood of hospital transport and admission for SNF residents may justify the increased upfront costs of a comprehensive telemedicine evaluation.

Footnotes

Section Editor: Phillips Perera, MD, RDMS

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Address for Correspondence: Joshua W. Joseph, MD, MS, MBE, Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 330 Brookline Avenue, Boston, MA 02215. Email: jwjoseph@bidmc.harvard.edu. 11 / 2020; 21:205 – 209

Submission history: Revision received January 27, 2020; Submitted May 27, 2020; Accepted July 11, 2020

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. This work was supported by a grant from the Gary and Mary West Health Institute.

REFERENCES

1. Burke RE, Rooks SP, Levy C, et al. Identifying potentially preventable emergency department visits by nursing home residents in the United States. J Am Med Dir Assoc. 2015;16(5):395-9.

2. Sourdet S, Lafont C, Rolland Y, et al. Preventable iatrogenic disability in elderly patients during hospitalization. J Am Med Dir Assoc. 2015;16(8):674-81.

3. LaMantia MA, Stump TE, Messina FC, et al. Emergency department use among older adults with dementia. Alzheimer Dis Assoc Disord. 2016;30(1):35-40.

4. Crosson FJ, Christianson J, Mathews JE. Medicare Payment Advisory Commission (MedPAC). Chapter 8: Skilled nursing facility services. Report to the Congress: Medicare Payment Policy. 2019:193-219. Available at: https://pswccp07.hs.uci.edu:9091/servlet/com.trend.iwss.user.servlet.sendfile?downloadfile=IRES-1681008446-C1125EC8-27654-27624-533.

5. Carpenter CR, Platts-Mills TF. Evolving prehospital, emergency department, and “inpatient” management models for geriatric emergencies. Clin Geriatr Med. 2013;29(1):31-47.

6. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc. 2011;59(4):745-53.

7. Ouslander JG, Naharci I, Engstrom G, et al. Lessons learned from root cause analyses of transfers of skilled nursing facility (SNF) patients to acute hospitals: transfers rated as preventable versus nonpreventable by SNF staff. J Am Med Dir Assoc. 2016;17(7):596-601.

8. Grabowski DC, Stewart KA, Broderick SM, Coots LA. Predictors of nursing home hospitalization: a review of the literature. Med Care Res Rev. 2008;65(1):3-39.

9. Gruneir A, Bell CM, Bronskill SE, et al. Frequency and pattern of emergency department visits by long-term care residents—a population-based study. J Am Geriatr Soc. 2010;58(3):510-7.

10. Brownell J, Wang J, Smith A, Stephens C, Hsia RY. Trends in emergency department visits for ambulatory care sensitive conditions by elderly nursing home residents, 2001 to 2010. JAMA Intern Med. 2014;174(1):156-8.

11. Redfield C, Desai S, Chang M, et al. Emergency telemedicine supported by on-site emergency responder technicians reduces EMS transports and emergency department visits from skilled nursing facilities. Prehosp Emerg Care. 2019;23(1):97-152.

12. Weiss AJ, Wier LM, Stocks C, et al. Overview of emergency department visits in the United States, 2011: Statistical Brief #174. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. 2014.

13. Mehrotra A, Jena AB, Busch AB, et al. Utilization of telemedicine among rural Medicare beneficiaries. JAMA. 2016;315(18):2015-6.

14. Hailey D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare. 2002;8(1_suppl):1-7.

15. Whitten PS, Mair FS, Haycox A, et al. Systematic review of cost effectiveness studies of telemedicine interventions. BMJ. 2002;324(7351):1434-7.

16. de la Torre-Díez I, López-Coronado M, Vaca C, et al. Cost-utility and cost-effectiveness studies of telemedicine, electronic, and mobile health systems in the literature: a systematic review. Telemed J E Health. 2015;21(2):81-5.

17. Potter AJ, Ward MM, Natafgi N, et al. Perceptions of the benefits of telemedicine in rural communities. Perspect Health Inf Manag. 2016:1-13.

18. Mollen CJ, Henien M, Jacobs LM, et al. Parent perceptions on transfers to pediatric emergency departments and the role of telemedicine. Pediatr Emerg Care. 2019;35(3):180-4.

19. Rubin MN, Wellik K, Channer D, et al. Systematic review of teleneurology: methodology. Front Neurol. 2012;3.

20. Belt GH, Felberg RA, Rubin J, et al. In-transit telemedicine speeds ischemic stroke treatment. Stroke. 2016;47(9):2413-5.

21. Bashshur RL, Krupinski EA, Thrall JH, et al. The empirical foundations of teleradiology and related applications: a review of the evidence. Telemed J E Health. 2016;22(11):868-98.

22. Rosenkrantz AB, Hanna TN, Steenburg SD, et al. The current state of teleradiology across the United States: a national survey of radiologists’ habits, attitudes, and perceptions on teleradiology practice. J Am Coll Radiol. 2019;16(12):1677-87.

23. Cossey TC, Jagolino A, Ankrom C, et al. No weekend or after-hours effect in acute ischemic stroke patients treated by telemedicine. J Stroke Cerebrovasc Dis. 2019;28(1):198-204.

24. Donley E, McClaren A, Jones R, et al. Evaluation and implementation of a telepsychiatry trial in the emergency department of a metropolitan public hospital. J Tech Hum Serv. 2017;35(4):292-313.

25. Reinhardt I, Gouzoulis-Mayfrank E, Zielasek J. Use of telepsychiatry in emergency and crisis intervention: current evidence. Curr Psychiatry Rep. 2019;21(8):63.

26. Dy P, Morin PC, Weinstock RS. Use of telemedicine to improve glycemic management in a skilled nursing facility: a pilot study. Telemed J E Health. 2013;19(8):643-5.

27. Grabowski DC, O’Malley AJ. Use of telemedicine can reduce hospitalizations of nursing home residents and generate savings for Medicare. Health Aff. 2014;33(2):244-50.

28. Gillespie SM, Wasserman EB, Wood NE, et al. High-intensity telemedicine reduces emergency department use by older adults with dementia in senior living communities. J Am Med Dir Assoc. 2019;20(8):942-6.

29. Mistry H, Garnvwa H, Oppong R. Critical appraisal of published systematic reviews assessing the cost-effectiveness of telemedicine studies. Telemed J E Health. 2014;20(7):609-18.

30. Mor V, Intrator O, Feng Z, et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff. 2010;29(1):57-64.