Abstract：
STUDY OBJECTIVE:We describe the characteristics and outcomes of enrollee-health plan disputes over insurance coverage for emergency department (ED) services at 2 large health maintenance organizations (HMOs) that apply the prudent layperson standard. METHODS:We abstracted information from a stratified random sample of approximately 3,500 appeals of coverage denials lodged by privately insured enrollees between 1998 and 2000 at 2 of the nation's largest HMOs (hereafter referred to as Plan 1 and Plan 2). We describe appeals involving ED services in terms of the timing of visits, patient age, costs of services, primary reason the patient sought care, and appeal outcome. RESULTS:Disputes over ED services accounted for approximately one half (52%) of postservice appeals at Plan 1 and one third (34%) at Plan 2. Nearly one half (46%) of ED appeals involved weekend, nighttime, or holiday visits to the ED; 22% were children's visits. The average cost of services in dispute was US$1,107. The most common general reasons for the ED visits in dispute were symptoms of illness (64%), injuries (22%), and services related to disease (8%). The most common presenting symptoms were abdominal pain, cramps, or spasms (7.6%); earaches or ear infections (3.4%); and lacerations/cuts (2.9%). Enrollees won more than 90% of appeals. CONCLUSION:The prevalence of ED cases among all appeals reflects disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard. The high rate at which enrollees win these appeals highlights significant disagreement in interpretation of the standard among different adjudicators within managed care organizations (medical groups and health plans). When enrollees fail to challenge denials that would be reversed on appeal, they bear the financial brunt of ambiguities in interpretation of the prudent layperson standard.
journal_name
Ann Emerg Medjournal_title
Annals of emergency medicineauthors
Gresenz CR,Studdert DMdoi
10.1016/s0196-0644(03)00637-1subject
Has Abstractpub_date
2004-02-01 00:00:00pages
155-62issue
2eissn
0196-0644issn
1097-6760pii
S0196064403006371journal_volume
43pub_type
杂志文章abstract：STUDY OBJECTIVE:Serum markers of smooth muscle destruction have been shown to be elevated in ectopic pregnancy, but they remain of questionable clinical utility. Our goal was to determine the clinical utility of 3 markers of smooth muscle destruction: creatine phosphokinase (CPK), smooth muscle heavy-chain myosin (SMHC...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1067/mem.2001.119851
更新日期：2001-12-01 00:00:00
abstract：STUDY OBJECTIVE:To determine if hypertonic saline/dextran (HSD) is effective in treating hemorrhage in the presence of dehydration. DESIGN:After surgical preparation, swine were euhydrated or dehydrated for 24 or 48 hours. Animals were bled 25 mL/kg over 60 minutes and treated with HSD. SETTING:Laboratory. PARTICIPA...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(05)80143-x
更新日期：1992-02-01 00:00:00
abstract：:Interstitial pregnancy is a rare and dangerous form of ectopic pregnancy that can be mistaken for a normal intrauterine pregnancy on ultrasonography, leading to catastrophic results. Increasingly, emergency physicians are using ultrasonography to diagnose intrauterine pregnancy. Emergency physicians should be aware of...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1067/mem.2002.125426
更新日期：2002-07-01 00:00:00
abstract：STUDY OBJECTIVE:To determine whether a set of published triage guidelines identifies patients who can safely be refused emergency department care. DESIGN:Historical cohort study. SETTING:A public hospital ED. TYPE OF PARTICIPANTS:All patients triaged during a one-week period who were not in the most acute triage cat...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(94)70042-7
更新日期：1994-02-01 00:00:00
abstract：:OxyContin (oxycodone hydrochloride controlled release) is a long-acting preparation of oxycodone that is used as an opioid analgesic to treat chronic pain conditions. We report a patient who ingested a massive quantity of OxyContin and had altered mental status, noncardiogenic pulmonary edema, and hypoventilation that...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1067/mem.2002.128143
更新日期：2002-10-01 00:00:00
abstract：:During a 3-month period, a 33-year-old man presented to the emergency department on 4 occasions with dyspnea, palpitations, and syncope. His initial presentation was accompanied by acute myocardial injury and ventricular fibrillation. An extensive evaluation spanned the 3 months and included echocardiography, cardiac ...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/j.annemergmed.2005.02.002
更新日期：2005-06-01 00:00:00
abstract：STUDY OBJECTIVE:We identify the incidence and predictors of missed fracture and characterize patterns of radiography performance in children with a diagnosis of radial head subluxation in the emergency department (ED) setting. METHODS:We queried the Pediatric Health Information System database for visits by children y...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/j.annemergmed.2020.09.002
更新日期：2021-02-01 00:00:00
abstract：STUDY OBJECTIVE:We determine the accuracy of an age-adjusted D-dimer threshold to detect pulmonary embolism in emergency department (ED) patients older than 50 years and describe current ED practices when evaluating possible pulmonary embolism. METHODS:This was a retrospective study of ED encounters for suspected pulm...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/j.annemergmed.2015.07.026
更新日期：2016-02-01 00:00:00
abstract：:Latex allergy, an IgE-mediated reaction to proteins retained in finished natural rubber latex products, has become one of the most pervasive problems in medicine. Latex allergy has resulted in death, progressive asthma, severe food allergy from cross-reactivity, and disability of health care professionals with the acc...
journal_title：Annals of emergency medicine
pub_type： 杂志文章,评审
doi：10.1016/s0196-0644(98)70073-3
更新日期：1998-12-01 00:00:00
abstract：:An important responsibility of emergency departments is the management of injuries sustained in assaults. Most assaults, including many causing serious injury, are not reported and not recorded by the police. This is important because police investigation and the conviction of offenders has a substantial deterrent eff...
journal_title：Annals of emergency medicine
pub_type： 杂志文章,评审
doi：10.1067/mem.2001.114317
更新日期：2001-10-01 00:00:00
abstract：:Epiglottitis in adults, while uncommon, is certainly not rare. Despite the increasing reports of the disorder in the literature, it continues to be misdiagnosed in emergency departments. The first step in the diagnosis of acute epiglottitis is for the emergency physician to think of it. The literature concerning the e...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(81)80463-5
更新日期：1981-01-01 00:00:00
abstract：:Electrolytes, BUN, and creatinine are some of the most frequently ordered laboratory tests. The use of these tests in emergency practice has not been studied critically, and few investigations of their use in other disciplines have been performed. A review of the available literature and an analysis of medical problem...
journal_title：Annals of emergency medicine
pub_type： 杂志文章,评审
doi：10.1016/s0196-0644(86)80586-8
更新日期：1986-03-01 00:00:00
abstract：:Patients evaluated by paramedics but not transported to the hospital account for 50% to 90% of emergency medical services lawsuits. We reviewed 2,698 consecutive paramedic run reports to examine documentation in these cases. Documentation criteria for prehospital patient release were history, physical examination, vit...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(05)82187-0
更新日期：1990-05-01 00:00:00
abstract：:To assess the relationship between conjunctival pH (pHcj), arterial pH (pHa), and cardiorespiratory variables during normal and low-flow conditions, hemorrhagic hypotension was induced in eight dogs. Conjunctival pH became significantly less than control values after a hemorrhage volume of 15 mL/kg (P less than .05); ...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(85)80630-2
更新日期：1985-09-01 00:00:00
abstract：STUDY OBJECTIVES:To confirm the ability of the esophageal detector device (EDD) to indicate positioning of endotracheal tubes (ETTs) in patients intubated under emergency conditions and to compare the performance of the EDD with that of end-tidal carbon dioxide (ETCO2). METHODS:This single-subject study comprising a p...
journal_title：Annals of emergency medicine
pub_type： 临床试验,杂志文章
doi：10.1016/s0196-0644(96)70162-2
更新日期：1996-05-01 00:00:00
abstract：STUDY OBJECTIVE:To determine the presence of cocaethylene, an active metabolite of the combination of cocaine and ethanol, among trauma patients who test positive for cocaine. METHODS:We assembled a case series of 416 consecutive urban trauma center patients with major trauma. Urine was tested for the presence of the ...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(96)70266-4
更新日期：1996-03-01 00:00:00
abstract：:The esophageal obturator airway (EOA) is in common use throughout the country. This report outlines an unexpected and serious complication: gastric rupture due to overinsufflation. A survey of the literature revealed that most of the known complications involve direct trauma to the esophagus or trachea. In our case, t...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(81)80240-5
更新日期：1981-07-01 00:00:00
abstract：:One hundred twenty-five pediatric emergency department patients were studied prospectively to determine whether any findings on the physical examination were predictive of abnormalities seen on chest radiograph. We attempted to find possible correlations between such clinical examination findings, recorded prior to ra...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(86)80374-2
更新日期：1986-07-01 00:00:00
abstract：STUDY OBJECTIVES:To develop a practical procedure for producing a nomogram describing the relationship between the osmolality gap and serum ethanol concentrations that is appropriate for the formulas and analytical methodologies in use at any laboratory. DESIGN:Retrospective review of serum sodium, glucose, urea nitro...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(05)81899-2
更新日期：1992-11-01 00:00:00
abstract：STUDY OBJECTIVE:Frequent emergency department (ED) users have been the targets of health care reform proposals and hospital crowding interventions, but it is not clear that common assumptions about this group are supported by data. We review the literature pertaining to frequent ED users, their demographics, acuity of ...
journal_title：Annals of emergency medicine
pub_type： 杂志文章,评审
doi：10.1016/j.annemergmed.2010.01.032
更新日期：2010-07-01 00:00:00
abstract：:Many of the approximately 400,000 deaths that occur outside of hospitals or chronic care facilities each year in the United States are not only expected but also welcomed as relief from terminal disease. However, patients who lack decision-making capacity cannot communicate to emergency medical services system and eme...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(05)81309-5
更新日期：1993-11-01 00:00:00
abstract：:A 19-year-old man who attempted suicide by ingesting approximately 600 mg fluoxetine (Prozac) and 140 mg loxapine (Loxitane) had two episodes of atrial flutter shortly thereafter. Admission serum fluoxetine, norfluoxetine, and loxapine levels were 1,053 ng/mL, 702 ng/mL, and 40 ng/mL, respectively. This case of atrial...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(94)70083-4
更新日期：1994-03-01 00:00:00
abstract：:A 27-year-old man was admitted to the emergency department with a fluphenazine decanoate-induced dystonia. He was treated with 125 mg diphenhydramine IV in four doses and 2 mg benztropine IM. A fluctuating response was observed before continued remission of the dystonia. Possible reasons for variable patient responses...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(87)80077-x
更新日期：1987-06-01 00:00:00
abstract：:This study was designed to investigate the efficacy of a decongestant-antihistamine preparation in combination with antibiotic treatment of acute otitis media. The effectiveness of a new Dimetapp (DIM) preparation was assessed in comparison with each of its components (brompheniramine maleate [BPM] and phenylephrine h...
journal_title：Annals of emergency medicine
pub_type： 临床试验,杂志文章,随机对照试验
doi：10.1016/s0196-0644(83)80125-5
更新日期：1983-01-01 00:00:00
abstract：:Experimental ischemia by the classic frostbite rabbit ear model clearly defined the role of thromboxane as a mediator of progressive dermal ischemia in frostbite injuries. The therapeutic groups consisted of the antiprostanoids, methylprednisolone, and aspirin combined with anti-thromboxane agents Aloe vera and methim...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(87)80758-8
更新日期：1987-09-01 00:00:00
abstract：:Hyperkalemia is a life-threatening electrolyte disturbance. The clinical presentation is most commonly related to its effects on cardiac conductivity and contractility, although weakness and respiratory compromise may occur. We describe what we believe to be the first reported case of life-threatening hyperkalemia pre...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(98)70107-6
更新日期：1998-07-01 00:00:00
abstract：STUDY OBJECTIVE:To describe the experience of croup at Princess Margaret Hospital for Children (PMH), the only tertiary pediatric hospital in Western Australia, from 1980 through 1995 with reference to the introduction of routine steroid treatment in the ICU in 1989, in the general hospital wards from 1989 through 1993...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/s0196-0644(96)70084-7
更新日期：1996-12-01 00:00:00
abstract：STUDY OBJECTIVE:Influenza has been linked to emergency department (ED) crowding, yet few studies have examined this association. We describe the relationship between ED crowding and influenza outbreaks. METHODS:A retrospective time series analysis was conducted in Toronto from January 1996 to April 1999 (n=170 weeks)....
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/j.annemergmed.2003.12.008
更新日期：2004-07-01 00:00:00
abstract：STUDY OBJECTIVES:To compare three different methods of teaching CPR to parents of infants at high risk for sudden cardiopulmonary arrest and to identify characteristics that predict difficulty in learning CPR. METHODS:We conducted a prospective, multicenter clinical trial of 480 parents and other infant caretakers. Su...
journal_title：Annals of emergency medicine
pub_type： 临床试验,杂志文章,多中心研究,随机对照试验
doi：10.1016/s0196-0644(98)70133-7
更新日期：1998-08-01 00:00:00
abstract：STUDY OBJECTIVE:Machine-learning algorithms allow improved prediction of sepsis syndromes in the emergency department (ED), using data from electronic medical records. Transfer learning, a new subfield of machine learning, allows generalizability of an algorithm across clinical sites. We aim to validate the Artificial ...
journal_title：Annals of emergency medicine
pub_type： 杂志文章
doi：10.1016/j.annemergmed.2020.11.007
更新日期：2021-01-15 00:00:00
