Is ED overuse a myth?

[deleted87716]

---

Members do not see this ad.

Are Most Emergency Room Visits Really Unnecessary?
http://www.slate.com/id/2247051/?from=rss

While the past decade has seen dramatic increases in the use of emergency care and ER crowding, ER care is but a tiny portion of the U.S. health care pie: less than 3 percent. The claim that unnecessary visits are clogging the emergency care system is also untrue: Just 12 percent of ER visits are not urgent. People also tend to think ER visits cost far more than primary care, but even this is disputable. In fact, the marginal cost of treating less acute patients in the ER is lower than paying off-hours primary care doctors, as ERs are already open 24/7 to handle life-threatening emergencies. And while we're at it, let's dispel one other myth: Despite the belief that the uninsured and undocumented flood ERs, most emergency room patients are insured U.S. citizens.

 

[GeneralVeers]

As with all questions of this type it depends. What defines "urgent"?

I think ACEP's 12% number is somewhat low, but I think they've cast a broad net for "urgent" complains. To me most of the young people with typical cough/cold symptoms are not "urgent" and shouldn't be in the ED.

At my community hospital I would put the non-urgent percentage as high as 30%, however that's purely subjective and based on my arbitrary criteria.

 

[deleted109597]

I tend to think we hit 12% at our county facility with medication refills. Or dental pain.
It has to be higher than that, but as Veers said, you need to define "urgent".

It is destined to go higher now though. Oh well, job security, and fewer non-paying customers. Except for the immigrant farmers. Once I had a day where 4 patients all had the same SSN. You would think people would look into this.

 

[irish frog]

This is an interesting article, Blue Dog. I think challenging the assumptions inherent to "healthcare reform" (I hate that term -- so ambiguous and cliche) will be critical to developing real solutions for a sustainable healthcare system.

Unfortuntely, I think this article also rests upon some very shaky assumptions. For example, the thought that primary care may cost more than the ED is a bit questionable.

"People also tend to think ER visits cost far more than primary care, but even this is disputable. In fact, the marginal cost of treating less acute patients in the ER is lower than paying off-hours primary care doctors, as ERs are already open 24/7 to handle life-threatening emergencies."

I agree that the marginal cost of an off-hours PCP visit would probably cost more than an ED visit at 2 am. However, this article assumes that a person would either go to an ER or go to an off-hours primary care doctor with whatever ails them, but is this true? If we provided the right incentives (higher deductibles, copays, etc. -- all after fair layperson review), wouldn't people choose to wait until regular hours to go to a primary care doctor? And, if they really did need to see a doctor at 2 am, wouldn't that be considered urgent? I think we're comparing apples and oranges here...

In this sense, we should be comparing ED rates to regular hours primary care rates. Speaking from the experience of a Health Econ intern working for a Managed Care Organization studying ED diversion rates in an RCT, one can easily show the ROI by diverting non-urgent cases from an ED to a PCP or nurse hotline. The embedded NEJM article says otherwise, but, again, remember that we're comparing apples and oranges. The marginal cost of an additional PCP visit during regular hours is phenomenally low. This may stem from the difference in ED and PCP approaches; ED's tend to be more diagnostic/procedural oriented (more costly), whereas PCP's tend to use more H&P (very cheap). (For obvious compliance reasons, I can't post my study here. You can either trust me on this one or not -- I don't blame you either way. I suspect I'll get torn apart for this one... fair enough...)

Also, interestingly enough, the embedded JAMA article when you click "uninsured" contradicts the Slate writer's point on ED v. PCP marginal costs.

Available data support the statement that care in the ED is more expensive than office-based care when appropriate, but this is true for all ED users, insured and uninsured.

Furthermore, I think the Slate article may have misinterpreted the intent of the JAMA article regarding the uninsured. The JAMA article was a database review that noticed many journal articles rest upon the assumption that the uninsured are crowding out the insured in the ED. In addition, the authors noted that there is not sufficient data to substantiate such assumptions. In other words, the JAMA article pointed out an absence of evidence. As my statistics professor would say, "absence of evidence IS NOT evidence of absence." We can disprove a null hypothesis, but definitively proving the alternate hpyothesis is pretty darn tough.

Please don't get me wrong -- this is a great article. I think we're on the right track. Challenging assumptions is the life blood of great science and medicine. Without articles like this, forcing us to provide evidence to substantiate our claims, we will not find the complex solutions for improving healthcare. I take issue with a few of the assumptions inherent to the author's argument, but the article is well-written, thoughtful, insightful, and I thoroughly enjoyed reading it! Thanks, Blue Dog!

 

[deleted87716]

Actually, I thought the article was laugh-out-loud ridiculous.

I just wondered what you guys thought.

 

[ccfccp]

I have to agree that this statement is pretty questionable. This is how they got there 12.1% (from the CDC paper from which the number came):

"Patients were triaged as needing to be seen immediately at 5.1 percent of ED visits, and within 1 to 14 minutes (emergent) at 10.8 percent of visits. Patients were triaged as needing to be seen within 15 to 60 minutes (urgent) at 36.6 percent, 1 to 2 hours (semiurgent) at 22.0 percent, and 2 to 24 hours (nonurgent) at 12.1 percent of visits. For the remaining 13.4 percent of visits, the triage status was not known or no triage system was used."

Seems like a pretty skewed distribution to me. The top part seems about right (althoguh we're at a higher acuity center...) but the "urgent" and "semi-urgent" parts seem awfully high. I also wonder how much billing for "urgent" visits had to do with this. We all try to document completely to upgrade our charts, and I wonder if this played a role...

 

[digitlnoize]

12% seems low to me. That being said, if we pretend it is a correct figure...wouldn't it be nice if our ED's were 12% more efficient at dealing with TRUE emergencies?

Also, the 12% neglects to take into account people who could have avoided the ED through preventive medicine. If you count the people who didn't NEED to have that MI, that % would skyrocket...

 

[doctorFred]

i've worked at a couple large EDs in the past few months, and based on my (admittedly limited) experience i would estimate one third to one half of all ED visits to be non-emergencies. i also find ACEPs figures to be laughable, and a bit insulting.. like their target audience doesn't already know the score?

 

[AbbyNormal]

I am not familiar with the statistics of ED patients but when I was a paramedic the majority of our calls were non-emergency. At that time (1980's) we were told that 20% of EMS calls were true emergencies but I don't know if that number was valid.

Last year I went to a local doc-in-a-box following N&V X 3days. They gave me an antibiotic and an anti-emetic and told me I was dehydrated (duh) and if I could not keep fluids down by the evening to go to the ED for some IV fluids. So that evening I showed up at the ED and told them my story and was kind of embarrassed about being there just for fluids. I waited two hours in the lobby, heard some other folks complaining about waiting five hours and still unseen. Then I went to puke in the toilet and some man had pissed and not flushed and I said, F*** this sh**, I can puke in my own toilet and I went home. I still don't understand why the doc who saw me earlier in the day told me to go to the ED rather than sending a liter or two of LR my way. 😕

 

[Stitch]

Actually, I thought the article was laugh-out-loud ridiculous.

I just wondered what you guys thought.

Yup.

Slate's been running a number of 'medical myth' i.e. docs are just whiners articles lately. They had one by Ezra Klein called 'the malpractice myth' going on about how malpractice isn't a big deal and that doctors kill people.

 

[TysonCook]

I'd put the figure at around 40-50% are not emergent

 

[docB]

Let me start by pointing out that Emergency Medicine as a profession and a specialty has a vested interest in not letting the public think that ERs are abused. If the public thinks we are treating a majority of non-emergent stuff we'll get our funding cut. So anything you see from ACEP, AAEM and most academic EM programs has some bias.

We know we see a lot of BS in the ED. That said it is (as others have mentioned appropriately) a question of definition. If you see a bogus 30 yo F with chest pain but she winds up getting a work up or even an admission it will be considered an "emergent" case by almost any definition you use retrospectively. Most studies define any case that gets a work up, eg. a chest xray for bronchitis, as "emergent."

The current liability crisis also affects this. We tend to look at everything, and this is how we're trained and appropriately so, through the lens of what is the worst that might happen and what's my liability exposure for it. We assume that people can reasonably self triage and they can't.

I think the best gauge would be to ask EPs "What percentage of your patients do you think could reasonably wait to see a PMD for 48 hours and then get an outpatient work up rather than coming to the ED?" Then I wager you'd get the 50-60% "non-emergent" figures we all know we see.

 

[GoodmanBrown]

12% seems low to me. That being said, if we pretend it is a correct figure...wouldn't it be nice if our ED's were 12% more efficient at dealing with TRUE emergencies?

Also, the 12% neglects to take into account people who could have avoided the ED through preventive medicine. If you count the people who didn't NEED to have that MI, that % would skyrocket...

While I agree that 12% seems low, isn't it kinda opening a huge can of worms to try to judge who could have avoided stuff via prevention? Can't you also then eliminate people who didn't NEED to have a car wreck? Or people who didn't NEED to get shot? I mean, shouldn't we all just sit in padded rooms eating kale to prevent any danger from befalling us?

 

[docB]

While I agree that 12% seems low, isn't it kinda opening a huge can of worms to try to judge who could have avoided stuff via prevention? Can't you also then eliminate people who didn't NEED to have a car wreck? Or people who didn't NEED to get shot? I mean, shouldn't we all just sit in padded rooms eating kale to prevent any danger from befalling us?

I see your point but you don't have to go to extremes to see the abuse. We're not talking about prevention in terms of "you should have lost weight so you didn't get a stroke" we're talking about "you should have seen your primary doc when this started 2 weeks ago rather than waiting until Saturday night." This really isn't about prevention in the preventative medicine sense. It's more about prevention of the ED visit in the resources management sense.

Just think about how many patients you see and ask "Why are you here in the ED with this?" and the answer is "My doctor is closed."

 

[GoodmanBrown]

I see your point but you don't have to go to extremes to see the abuse. We're not talking about prevention in terms of "you should have lost weight so you didn't get a stroke" we're talking about "you should have seen your primary doc when this started 2 weeks ago rather than waiting until Saturday night." This really isn't about prevention in the preventative medicine sense. It's more about prevention of the ED visit in the resources management sense.

Just think about how many patients you see and ask "Why are you here in the ED with this?" and the answer is "My doctor is closed."

A very solid point. Digitalnoize mentioned something about not needing to have an MI which is what I took issue with. I definitely agree with what you're referring to.