Agency Information Collection Activities: Proposed Collection; Comment Request, 4718-4721 [2014-01709]
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Federal Register / Vol. 79, No. 19 / Wednesday, January 29, 2014 / Notices
December 6, 2013, the IRS announced
that as of January 1, 2014, the relocation
mileage rate would decrease to $0.235
per mile for the 12-month period ending
on December 31, 2014. Thus, the
reimbursement rate for POVs used in
conjunction with official relocation will
also be $0.235 for the same period. FTR
Bulletin 14–04 is attached. FTR Bulletin
14–04 and all other FTR bulletins may
be found at www.gsa.gov/
federaltravelregulation.
Dated: November 13, 2013.
E.J. Holland, Jr.,
Assistant Secretary for Administration.
This notice is effective January
29, 2014 and applies to relocations
performed on or after January 1, 2014,
through December 31, 2014.
FOR FURTHER INFORMATION CONTACT: Mr.
Ed Davis, GSA, Office of Governmentwide Policy (M), Office of Asset and
Transportation Management (MA), at
202–208–7638 or via email at ed.davis@
gsa.gov. Please cite FTR Bulletin 14–04.
Agency Information Collection
Activities: Proposed Collection;
Comment Request
DATES:
Dated: January 17, 2014.
Anne E. Rung,
Associate Administrator, Office of
Government-wide Policy.
[FR Doc. 2014–01705 Filed 1–28–14; 8:45 am]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Office of the Secretary
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Office of the Assistant Secretary for
Financial Resources (ASFR);
Statement of Organization, Functions,
and Delegations of Authority
Part A, Office of the Secretary,
Statement of Organization, Functions
and Delegations of Authority for the
Department of Health and Human
Services (HHS) is being amended at
Chapter AM, Office of the Assistant
Secretary for Financial Resources, as
last amended at 77 FR 19666–67, dated
April 2, 2012. This reorganization will
eliminate the Office of Executive
Program Information (AMW) within
ASFR through the following changes:
A. Under Section AM.10
Organization, delete the last sentence of
the section in its entirety and replace
with the following:
The office consists of the following
components:
• Immediate Office of the Assistant
Secretary (AM).
• Office of Budget (AML).
• Office of Finance (AMS).
• Office of Grants and Acquisition
Policy and Accountability (AMT).
B. Under Section AM.20 Functions,
delete Chapter AMW, Office of
Executive Program Information (OEPI),
in its entirety.
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[FR Doc. 2014–01712 Filed 1–28–14; 8:45 am]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Agency for Healthcare Research and
Quality
Agency for Healthcare Research
and Quality, HHS.
ACTION: Notice.
AGENCY:
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 doris.lefkowitz@ahrq.hhs.gov.
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 doris.lefkowitz@ahrq.hhs.gov.
SUPPLEMENTARY INFORMATION:
SUMMARY:
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
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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
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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
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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, EastBaltimore Medical Center (a primary
referral site for patients without primary
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4719
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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Federal Register / Vol. 79, No. 19 / Wednesday, January 29, 2014 / Notices
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, indepth 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
Number of
responses per
respondent
Number of
respondents
Form name
Hours per
response
Total burden
hours
Pilot Test of the Emergency Department Discharge Tool (EDT)
EDT ..................................................................................................................
One Month Patient Follow-up ..........................................................................
Three Month Patient Follow-up .......................................................................
900
900
180
1
1
1
20/60
10/60
5/60
300
150
15
3
8
8
8
1
1
1
1
2
2
2
2
6
16
16
16
Community Healthcare Provider Interview ......................................................
Patient Interview ..............................................................................................
ED Director Interview .......................................................................................
6
15
3
1
1
1
2
1
1
12
15
3
Total ..........................................................................................................
2,031
NA
NA
549
Implementer Focus Groups
RA Focus Group ..............................................................................................
EDT Implementer (non-RA) #1 Focus Group ..................................................
EDT Implementer (non-RA) #2 Focus Group ..................................................
EDT Implementer (non-RA) #3 Focus Group ..................................................
Key Informant Interviews
EXHIBIT 2—ESTIMATED ANNUALIZED COST BURDEN
Number of
respondents
Form name
Total
burden hours
Average
hourly wage
rate*
Total
cost burden
Pilot Test of the Emergency Department Discharge Tool (EDT)
900
900
180
300
150
15
a $22.01
3
8
8
8
6
16
16
16
d 17.86
Community Healthcare Provider Focus Group ................................................
Patient Interview ..............................................................................................
ED Director Interview .......................................................................................
6
15
3
12
15
3
a 22.01
e 97.30
544
330
292
Total ..........................................................................................................
2,031
549
NA
12,825
EDT ..................................................................................................................
One Month Patient Follow-up ..........................................................................
Three Month Patient Follow-up .......................................................................
a 22.01
a 22.01
$6,603
3,302
330
Implementer Focus Groups
RA Focus Group ..............................................................................................
EDT Implementer (non-RA) #1 Focus Group ..................................................
EDT Implementer (non-RA) #2 Focus Group ..................................................
EDT Implementer (non-RA) #3 Focus Group ..................................................
b 27.42
b 27.4
b 27.42
107
439
439
439
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Key Informant Interviews
c 45.36
* 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).
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Federal Register / Vol. 79, No. 19 / Wednesday, January 29, 2014 / Notices
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
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Agency for Healthcare Research and
Quality
Agency Information Collection
Activities: Proposed Collection;
Comment Request
Agency for Healthcare Research
and Quality, HHS.
ACTION: Notice.
AGENCY:
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:
‘‘SelectMD 2.0 Clinician Choice
Experiment.’’ 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 March 31, 2014.
ADDRESSES: Written comments should
be submitted to: Doris Lefkowitz,
Reports Clearance Officer, AHRQ, by
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SUMMARY:
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email at doris.lefkowitz@ahrq.hhs.gov.
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 doris.lefkowitz@ahrq.hhs.gov.
SUPPLEMENTARY INFORMATION:
Proposed Project
SelectMD 2.0 Clinician Choice
Experiment
This study builds on previous
research conducted as part of the
Consumer Assessment of Healthcare
Providers and Systems (CAHPS)
program to explore new ways of
integrating patient comments with other
performance metrics in web-based
quality reports for consumers to support
their choice of physicians. Our previous
consumer choice study, referred to as
SelectMD 1.0 (approved by OMB on 3/
8/10 under OMB Control Number 0935–
0161), revealed important risks and
opportunities of using patient comments
that require additional research in order
to develop effective guidance for report
sponsors. Sponsors of performance
reports in both the public and private
sectors, including Federal agencies such
as the Centers for Medicare & Medicaid
Services (CMS), have indicated strong
interest in receiving such guidance on
strategies for effectively incorporating
patient comments to increase
consumers’ use of public reports and to
enhance their ability to interpret CAHPS
and other performance measures.
This follow-on study (referred to as
SelectMD 2.0) will use an experimental
design to test different methods of
incorporating patient comments along
with CAHPS survey results, the
Healthcare Effectiveness Data and
Information Set (HEDIS)-like measures
of effective clinical treatments, and
indicators of patient safety in web-based
physician quality reports. The study
will help AHRQ understand how people
choose a doctor as their regular source
of medical care and advice.
The study has three stages. In the first
stage, respondents will be asked some
questions about their health care
experiences and how they go about
choosing a doctor. In the second stage
the respondents will log onto an
experimental Web site that has
information about a fictitious set of
doctors from which to choose.
Respondents will be asked to use the
information on the Web site to select a
doctor who they think would be the best
for their health care needs. Although
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4721
they will not really be selecting a
doctor, they will be asked to consider
the choice as carefully as if they were
making it for themselves. In the third
stage, following their selection of a
doctor, respondents will answer a set of
questions about how they made their
choice of doctor, how useful they found
the Web site, and how confident they
were in the choice they made.
This research has the following goals:
(1) To expand on the findings from
AHRQ’s previous choice experiment
regarding how including narrative
patient comments in web-based
physician quality reports influences the
ways in which consumers learn about
and select among clinicians, and
(2) to assess whether and how patient
comments can be presented in a way
that promotes learning about physician
quality and complements rather than
detracts from standardized measures of
quality.
This study is being conducted by
AHRQ through its contractors, RAND
and Yale University, 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
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 the goals of this project the
following data collections will be
implemented over the three stages of the
experiment:
(1) Pre-Choice Survey—The purpose
of this survey is to measure the
respondents’ previous exposure to
information on health care provider
performance and how they go about
choosing a physician.
(2) Experimental Web site—The
purpose of this site is to present
different combinations and displays of
performance information that
respondents will use to select a doctor.
Respondents will be randomly assigned
to one of eight different versions of the
experimental SelectMD Web site that
will vary according to the level of detail
presented, how patient comments are
grouped and labeled, whether
respondents can choose which and how
much information to review, and
whether respondents have access to live
telephone assistance when making their
choices.
(3) Post-Choice Survey—The purpose
of the post-choice survey is to assess
how respondents made their doctor
selection, how useful the Web site
version assigned to them was in helping
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]]>Agencies
[Federal Register Volume 79, Number 19 (Wednesday, January 29, 2014)]
[Notices]
[Pages 4718-4721]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-01709]
-----------------------------------------------------------------------
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.
-----------------------------------------------------------------------
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
doris.lefkowitz@ahrq.hhs.gov.
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
doris.lefkowitz@ahrq.hhs.gov.
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
[[Page 4720]]
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
----------------------------------------------------------------------------------------------------------------
Number of
Form name Number of responses per Hours per Total burden
respondents respondent response hours
----------------------------------------------------------------------------------------------------------------
Pilot Test of the Emergency Department Discharge Tool (EDT)
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Implementer Focus Groups
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Key Informant Interviews
----------------------------------------------------------------------------------------------------------------
Community Healthcare Provider Interview......... 6 1 2 12
Patient Interview............................... 15 1 1 15
ED Director Interview........................... 3 1 1 3
---------------------------------------------------------------
Total....................................... 2,031 NA NA 549
----------------------------------------------------------------------------------------------------------------
Exhibit 2--Estimated Annualized Cost Burden
----------------------------------------------------------------------------------------------------------------
Number of Total burden Average hourly Total cost
Form name respondents hours wage rate* burden
----------------------------------------------------------------------------------------------------------------
Pilot Test of the Emergency Department Discharge Tool (EDT)
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Implementer Focus Groups
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
Key Informant Interviews
----------------------------------------------------------------------------------------------------------------
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
---------------------------------------------------------------
Total....................................... 2,031 549 NA 12,825
----------------------------------------------------------------------------------------------------------------
* 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
