Reasons for Using the Emergency Department: Results of the EMPATH Study

Objectives: Emergency Medicine Patients' Access To Healthcare (EMPATH) was a cross-sectional, observational study conducted to identify the principal reasons why patients seek care in hospital emergency departments (EDs) in the United States. Methods: Twenty-eight U.S. hospitals, stratified by geographic region and hospital characteristics, participated in this study. Demographic, clinical, and insurance data were collected for a 24-hour period at each site, using chart reviews and a structured interview administered to all consenting adult patients seeking treatment during that period. Patients' reasons for presenting to the ED were assessed by their level of agreement (on a three-point Likert scale) with 21 carefully worded statements designed to capture a range of possible reasons for seeking care in the ED. Factor analysis was used to consolidate highly correlated responses and to identify the principal factors explaining patients' reasons for coming to the ED. Results: A total of 1,579 patient interviews and 2,004 chart reviews were obtained from a diverse sample that was 55.4% female, 58.3% white, 28.3% African American, 7.0% Hispanic, and 6.0% other ethnic groups. This exploratory analysis yielded five factors characterizing patients' principal reasons for seeking ED care, with medical necessity the most frequent, followed by ED preference, convenience, affordability, and limitations of insurance. Conclusions: Use of the ED is, for most people, an affirmative choice over other providers rather than a last resort; it is often a choice driven by lack of access to or dissatisfaction with other sources of care.     

"Inappropriate" Emergency Department Use: A Comparison of Three Methodologies for Identification

Objective: To determine the level of agreement between the rates of “inappropriate” ED visits assigned to a cohort of ambulatory patients based on three methods of defining ED use appropriateness. Methods: Ambulatory adult patients seen at one urban, university-based teaching hospital ED between 8 am and midnight during select days from April to June 1994 were assessed regarding-the appropriateness of their ED visits. Patients triaged to acute resuscitation rooms in the ED were excluded. Eligible patients were asked to complete a 90–question survey including demographics and health service use (response rate 81%). The appropriateness of ED use was assessed for consenting respondents by 1) application of a list of 51 nonemergent complaints that have been used by managed care providers and previously published (triage), 2) use of ten explicit criteria (e. g., need for parenteral medication) from prior publications (explicit), and 3) the consensus of two emergency physicians (EPs) reviewing the records of ED patients (phys). All three methods were applied at the time of retrospective chart review. The agreement between methods was evaluated using kappa scores. Results: Of the 892 eligible respondents, 64% were white, 54% were employed, 50% were female, and 29% were uninsured. Of the respondents, 26% had no regular source of ambulatory care and 25% considered the ED their regular source of care. The assigned rates of “inappropriate” visits using the three definitions were triage, 58%; phys, 47%; and explicit, 42%. Of those deemed “inappropriate” by the explicit criteria, 81% also were judged as “inappropriate” by the triage criteria, and 72%, by the phys criteria. Of those patients deemed “inappropriate” by the triage criteria, 59% also were judged as “inappropriate” by the explicit criteria, and 66%, by the phys criteria. Levels of agreement (kappas) were triage/explicit, 0.39; triage/phys, 0.42; and explicit/phys, 0.42. Conclusion: There is only moderate agreement between different methods of determining appropriateness of ED use. Until further refinement is made in triage assessment, managed care organizations and EPs should remain cautious when implementing a protocol that defines and restricts “inappropriate” ED visits.     

Access to Care A Review of the Emergency Medicine Literature

The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. In the 1980s, the characterization of "nonurgent ED visits" as "inappropriate" and high ED charges led to the targeting of non-emergency ED care as a potential source of savings. During the 1990s the literature reveals multiple attempts to identify "inappropriate" ED visits and to develop strategies to triage these visits away from the ED. By the late 1990s, demonstration of the risks of denying emergency care and more sophisticated analyses of actual costs led to reconsideration of initiatives to limit access to ED care and renewed focus on the critical role of the ED as a safety net provider. In recent years, "de facto" denials of emergency care due to long ED waiting times and other adverse consequences of ED crowding have begun to dominate the emergency medicine health services literature.     

Continuous Quality Improvement Reduces Length of Stay for Fast-track Patients in an Emergency Department

Objective: To demonstrate how continuous quality improvement (CQI) can identify rational and effective means to reduce length of stay for minor illness/injury in an ED.
Methods: A CQI team documented the process of fast-track (FT) patient flow and prioritized the causes of delay. In Phase I, two solutions were implemented. In this Phase II of the study, three changes were implemented, including expansion of the FT area, realignment to provide a full-time FT nurse, and a detailed, stricter triage classification. The outcome was assessed by examining the interval from presentation to release from the ED (length of stay; LOS). Differences were ascertained by analysis of variance for consecutive FT patients not requiring radiography, ECG, or blood testing. Intervals from three pre-Phase II intervention 48-hour periods and one post-Phase II intervention 48-hour period were analyzed.
Results: Before the Phase I changes, the mean ± SD LOS was 92 ± 46 min. After the Phase I changes, the LOS was 67 ± 31 min. After the Phase II changes, this was reduced to 57 ± 34 min (p < 0. 05).
Conclusion: The formal application of CQI techniques in the ED can change patient flow and reduce LOS for FT patients.     

Analysis of Costs, Length of Stay, and Utilization of Emergency Department Services by Frequent Users: Implications for Health Policy

In efforts to decrease emergency department (ED) crowding and health care costs, frequent users of ED services have been targeted for interventions to decrease their utilization. Previous studies have had different definitions for "frequent users" and have considered all frequent users as a homogeneous group. To the authors' knowledge, no study has examined visit characteristics and resource utilization of different levels of frequent use. OBJECTIVES: 1) to determine the rates of ED utilization by five user groups defined by number of annual visits, 2) to examine variations in visit characteristics by frequency of ED use, and 3) to compare levels of resource utilization among frequent user groups. METHODS: This was a retrospective, cross-sectional study of clinical and financial records for all ED visits to an urban, academic hospital in 2001. Multinomial logistic and linear regression models were used for analyses. Estimates were corrected for multiple comparisons (with Bonferroni corrections), where applicable, and adjusted for clustering within individuals (with Huber-White estimators). Outcome measures were triage acuity, diagnosis-related group (DRG) severity, disposition status, primary complaint, medical diagnosis, hospital inpatient length of stay, payment method, costs, and demographics. RESULTS: Patients with three to 20 visits were more likely to be admitted to the hospital than patients visiting once or twice. Patients visiting more than 20 times were less likely to require hospital admission and more likely to present with "nonurgent" conditions, have lower severity scores, and elope or leave the ED without medical attention than patients visiting the ED once. The group had fewer inpatient days and lower average costs than patients visiting once. Patients with six to 20 visits had traditional Medicaid coverage more often than those with one or two visits. Virtually no patients visiting more than 20 times had Medicare or Medicaid managed care, a health maintenance organization, or a preferred provider organization. CONCLUSIONS: Frequent ED users are a heterogeneous group. Many patients previously thought to overutilize the ED for socioeconomic or insignificant medical problems are as sick as less-frequent ED users. There is a small subgroup with more than 20 visits who are less ill or injured but also incurred lower-than-average costs per visit.     

Emergency Department Use by Adult Medicaid Patients after Implementation of Managed Care

OBJECTIVE: To determine whether the advent of a mandatory Medicaid managed care (MMC) plan had any effect on emergency department (ED) utilization by adult Medicaid patients at an urban teaching hospital. METHODS: This was a retrospective cohort study using four years of ED records encompassing the year prior to initiation of MMC (1994-95), the enrollment year (1995-96), and two years after the program had matured (1996-98). RESULTS: Total ED census declined slightly, then returned to 1995 levels. Emergency department use by MMC patients declined steadily, with the 1998 figure of 5,888 representing a 40% decline over the pre-MMC volume of 9,849. Visits by MMC patients with acute illness or injury declined by 29%; MMC low-acuity visits decreased by 43%. Medicaid managed care low-acuity after-hours/weekend visits declined by 19%, then leveled off. The MMC enrollment was stable throughout the study period. CONCLUSIONS: Mandatory managed care can be associated with considerable diminution in ED use by Medicaid patients. This decline is most pronounced in low-acuity triage categories, and least evident after hours and on weekends.     

Impact of Ambulance Diversion Policies in Urban, Suburban, and Rural Areas of Central Maryland

As a method to control patient flow to overburdened hospitals, effective emergency medical services (EMS) systems provide policies for ambulance diversion. The Maryland state EMS system supports two types of alert for general hospital use: red alert, aimed at limiting the delivery of patients who may require intensive care unit (ICU) admission, and yellow alert, aimed at preventing further overload of already overtaxed emergency departments (EDs). OBJECTIVE: To examine the effect of those alert policies in different geographical environments, urban, suburban, and rural. METHODS: Alert data for 23 hospitals in Central Maryland and ambulance arrival data for approximately 138,000 ambulance calls during calendar year 1996 were combined and analyzed. The impacts of diversion practices in the geographic areas were compared. RESULTS: Red alert reduced volume in all patient acuity levels in all geographic areas by a statistically significant 0.4 patient/hr. Yellow alert diverted low-acuity patients at the rate of 0.13 patient/hr (p<0.001) in urban areas and at the rate of 0.16 patient/hr (p<0.001) in suburban areas, but had minimal impact in the flow of patients in the rural environment. CONCLUSIONS: The ED diversion policy has some limited effect in preventing further patient volume in urban and suburban areas, but has virtually no impact in rural areas. However, an ICU diversion policy diverts patients of all acuities uniformly and inordinately diverts patients not likely to require ICU admissions while having only minimal impact on patients who do require ICU resources. The impact of red alert is uniform in all geographic areas. The impact and efficacy of ambulance diversion policies should be evaluated to ensure they are having the intended effect. While perhaps initially effective, the impact of alert policies may change over time.     

Understanding the Value of Emergency Care: A Framework Incorporating Stakeholder Perspectives

Background

In the face of escalating spending, measuring and maximizing the value of health services has become an important focus of health reform. Recent initiatives aim to incentivize high-value care through provider and hospital payment reform, but the role of the emergency department (ED) remains poorly defined.

Objectives

To achieve an improved understanding of the value of emergency care, we have developed a framework that incorporates the perspectives of stakeholders in the delivery of health services.

Methods

A pragmatic review of the literature informed the design of this framework to standardize the definition of value in emergency care and discuss outcomes and costs from different stakeholder perspectives. The viewpoint of patient, provider, payer, health system, and society is each used to assess value for emergency medical conditions.

Results

We found that the value attributed to emergency care differs substantially by stakeholder perspective. Potential targets to improve ED value may be aimed at improving outcomes or controlling costs, depending on the acuity of the clinical condition.

Conclusion

The value of emergency care varies by perspective, and a better understanding is achieved when specific outcomes and costs can be identified, quantified, and measured. Using this framework can help stakeholders find common ground to prioritize which costs and outcomes to target for research, quality improvement efforts, and future health policy impacting emergency care.     

Emergency Department Utilization by the Elderly: Analysis of the National Hospital Ambulatory Medical Care Survey

Objective : To characterize the ED utilization patterns of the elderly population using nationally representative data.
Methods : A secondary analysis was performed using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationwide, stratified probability sample of ED encounters. Using these physician-reported data, the demographics, patient complaints, physician diagnoses, and dispositions were compared by age group, i.e., young-old (age 65–84 years) vs old-old (age ±85 years).
Results : The elderly (age ±65 years) represented 5,038 (19.6%) of 25,646 ED encounters for all adults (age ±18 years). The geriatric age groups (ages 65–74, 75–84, and ±85 years) accounted for 45.3%, 37.4%, and 17.2% of all the encounters by the elderly. The proportions of female patients and white patients were higher with increasing age. The proportion of elderly patients hospitalized was 4 times that of younger adults and reflected monotonic increase with increasing age among elders. Patient complaints and physician diagnoses were generally similar for the young-old (65–84 years) and the old-old (±85 years).
Conclusions : These findings are consistent with previous single-center studies of geriatric ED patients. This data source may be useful for investigation of clinical issues related to the care of elderly ED patients.     

A Health Promotion Intervention for Families in a Medicaid Managed Care Plan

OBJECTIVE: To determine whether implementation of an intervention based on a model of health promotion will encourage patients to seek care from their primary care provider (PCP) and reduce visits to the pediatric ED (PED) for minor illness. METHODS: Prospective, randomized, controlled study in the PED of an urban children's hospital (CH). Children <13 months old, enrolled in a Medicaid managed care plan, who identified the CH as their site for primary care and presented to the PED for evaluation of minor illness were enrolled after being seen by the triage nurse, before being seen by a physician. Subjects were randomly assigned to the intervention (I) group or control (C) group. Parents of all enrollees completed a survey about health care utilization habits. Each family in the I group received health promotion teaching from a single investigator. The intervention consisted of a review of the child's medical record with the parents, an explanation of what to expect at future well-child visits, and a discussion of the role of the PCP. A follow-up appointment was also provided prior to discharge from the PED. The C group received usual care. Use of health care by all subjects was tracked for one year by medical record review and phone interviews at six and 12 months. RESULTS: 102 subjects in the I group and 93 in the C group (mean +/- SD ages 6.4 months +/- 3.8 and 7.2 months +/- 3.9, respectively, p = 0.15) were enrolled from March 1996 to November 1996. The two groups were similar with respect to demographics and overall health status at enrollment. At study entry: 94 of 102 (92%) subjects in I and 87 of 93 (94%) in C had made at least one visit to the PED in the previous 12 months (p = 0.11); 95 of 102 (93%) in I and 75 of 93 (81%) in C had seen their PCP at least once for well-child care (p = 0.24). Twelve-month follow-up by medical record review was completed for all subjects; phone interviews were completed in 90 of 102 (88%) in I and 80 of 93 (86%) in C. At 12-month follow-up: 84 of 102 (82%) in I and 73 of 93 (78%) in C had made at least one visit to the PED (p = 0.59); 81 of 102 (79%) in I and 77 of 93 (83%) in C had made at least one visit to their CH PCP (p = 0.54). CONCLUSIONS: There was no difference in health care utilization between the intervention and control groups at 12-month follow-up. The health promotion intervention did not alter utilization habits.     

Ethics of Emergency Department Triage: SAEM Position Statement

Emergency department overcrowding, the growth of managed care, and the high cost of emergency care are creating pressures to triage patients away from US. EDs. Paradoxically. this pressure to limit patient access to EDs has increased in spite of federal laws that restrict patient triage and transfer The latter regulations view EDs as the safety net for the US health care system. The SAEM Ethics Committee evaluated the ethical implications of policies that triage patients nut of the ED prior to complete evaluation and treatment. The committee used these implications to develop practical guidelines, which are reported.     

Emergency Department Utilization in the United States and Ontario, Canada

Objectives: The current crisis in the emergency care system is characterized by worsening emergency department (ED) overcrowding. Lack of health insurance is widely perceived to be a major contributing factor to ED overcrowding in the United States. This study aimed to compare ED visit rates in the United States and Ontario, Canada, according to demographic and clinical characteristics.
Methods: This was a cross sectional study consisting of a nationally representative sample of 40,253 ED visits included in the 2003 National Hospital Ambulatory Medical Care Survey in the United States, and all ED visits recorded during 2003 by the National Ambulatory Care Reporting System in Ontario, Canada. The main outcome was the number of ED visits per 100 population per year.
Results: The annual ED visit rate in the United States was 39.9 visits (95% confidence interval = 37.2 to 42.6) per 100 population, virtually identical to the rate in Ontario, Canada (39.7 visits per 100 population). In both the United States and Ontario, Canada, those aged 75 years and older had the highest ED visit rate and women had a slightly higher ED visit rate than men. The most common discharge diagnosis was injury/poisoning, accounting for 25.6% of all ED visits in the United States and 24.7% in Ontario, Canada. Overall, 13.9% of ED patients in the United States were admitted to hospitals, compared with 10.5% in Ontario, Canada.
Conclusions: ED visit rates and patterns are similar in the United States and Ontario, Canada. Differences in health insurance coverage may not have a substantial impact on the overall utilization of emergency care.