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[Federal Register Volume 78, Number 166 (Tuesday, August 27, 2013)]
[Notices]
[Pages 52925-52927]
From the Federal Register Online via the Government Printing 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 
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) 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
----------------------------------------------------------------------------------------------------------------
                                                                          Number of
                                                            Number of     responses     Hours per       Total
                        Form name                          respondents       per        response       burden
                                                                         respondent                     hours
----------------------------------------------------------------------------------------------------------------
                           Pilot Test of the Emergency Department Discharge Tool (EDT)
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
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
                                                         -------------------------------------------------------
    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
----------------------------------------------------------------------------------------------------------------
                           Pilot Test of the Emergency Department Discharge Tool (EDT)
----------------------------------------------------------------------------------------------------------------
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
----------------------------------------------------------------------------------------------------------------
                                   Post Pilot Test Focus Groups and Interviews
----------------------------------------------------------------------------------------------------------------
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
                                                         -------------------------------------------------------
    Total...............................................         2,696           708            na        16,359
----------------------------------------------------------------------------------------------------------------
\*\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
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