551986
research-article2014
JPCXXX10.1177/2150131914551986Journal of Primary Care & Community HealthCuroe et al
Research Letter Journal of Primary Care & Community Health 2015, Vol. 6(2) 134–136 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131914551986 jpc.sagepub.com
A Day in the Life of an Urban Emergency Department
Ann Curoe1, John Kralewski1, Megan Savage1, and Beth Lindholm1
Abstract Importance: The annual number of patient visits to emergency departments (EDs) continues to increase. Patients seen in the ED for nonemergent conditions potentially increase the cost of health care and lead to overcrowding in EDs. Objective: To gain insights into the factors leading to nonemergent use of hospital EDs. Design, Setting, and Participants: During a 24-hour period, we interviewed 67 patients in an urban ED. A total of 232 patients were seen in the ED and the hospital provided all claims data. Intervention: None. Main Outcomes and Measures: Elicit and record patient-stated reasons for seeking care in the ED. Results: Interview results showed that 90% of patients had a primary care clinic although 23% of those clinics were not affiliated with the hospital. Of the 67 interviewed patients, 72% reported they came to the ED because their condition was an emergency, 79% had spoken to someone prior to going to the ED, but only 30% consulted medical personnel. Conclusions and Relevance: Patients did not go to the ED because they lacked a primary care clinic. Most patients did not discuss their condition with medical personnel prior to going to the ED. Informing patients of clinic and hospital affiliations may improve continuity of care and access to electronic health records. Keywords access to care, emergency visits, primary care, managed care, patient-centeredness
Introduction The increasing use of emergency departments (EDs) for nonemergent visits is overcrowding these facilities and potentially increasing the cost of care.1-3 While the magnitude of ED use has been well documented, little is known about the factors influencing these use patterns and even less is known about effective interventions.4,5 Our study was designed to contribute to a better understanding of the factors influencing these use patterns by conducting indepth interviews with patients and documenting the demographic characteristics and insurance status of these patients.
Methods Study Sample This study was conducted at an urban hospital and was approved by the hospital’s institutional review board. On a week day over a continuous 24-hour period trained interviewers were in the ED. Patients were seen initially by a physician and/or a nurse. Patients who were medically or psychiatrically unstable, intoxicated, demented, or who did not speak English were not interviewed. Parents or guardians were asked to answer the questions for those younger than 18. Those patients participating in the study received
a $10 gift card. During the 24-hour period, 232 patients were seen in the ED and 67 (29%) were interviewed. The hospital provided deidentified demographic data, reason for visit and facility and professional payment claims for all of the patients. To protect patient privacy, we did not link patient interview responses to the data provided by the hospital.
Study Design The interviewers asked patients if they had a usual source of care, how often they sought medical care in the past 12 months, if they consulted anyone prior to going to the ED, health insurance status, educational level, and age. The interviewers also asked patients to tell them some of the reasons why they came to the ED. After patients answered this openended question, they were asked if in addition any of the following influenced their decision: no appointment needed, transportation availability, inability to get an appointment at 1
Medica Research Institute, Minnetonka, MN, USA
Corresponding Author: Ann Curoe, Medica Research Institute, Mail Route CW105, PO Box 9310, Minneapolis, MN 55440-9310, USA. Email: [email protected]
Downloaded from jpc.sagepub.com by guest on November 19, 2015
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Curoe et al Table 1. Patient Interview Responses. Age, years Percentage Educational level Percentage Health insurance Percentage Type of insurance Percentage Clinic as usual source of care Percentage Clinic is affiliated with hospital Percentage Number of ED visits previous 12 months Percentage Spoke to someone prior to going to ED Percentage With whom did you speak Percentage Reason for ED Visit
5
10
9
Nurse line
Insurance provider 1 Prefer to go to ED
Able to get a ride to ED
24
19
15 Unable to get clinic appointment or clinic is closed 27
>65 18
Abbreviation: ED, emergency department.
their clinic, preferred to receive care in the ED, or because they thought they had a medical emergency.
Results During this 24-hour study period, 91% of the 232 patients seen in the ED had health insurance. Almost half had Medicaid coverage (45%), 30% had employer-based health insurance, 25% Medicare, and less than 10% were uninsured. The patients were distributed across all age groups 65 years (19%). Females comprised 52% of the patients and 47 (20%) patients were admitted to the hospital. Table 1 shows that the 67 patients interviewed were similar to the overall 24-hour patient population in terms of age 65 years (18%). The patients interviewed had a similar insurance status to the entire patient population with 38% covered by Medicaid, 38% by employer-based plans, 23% by Medicare, and 13% uninsured. Most patients (90%) listed a clinic as their usual source of care although 23% of these patients listed a clinic whose
providers do not have privileges at this hospital. The majority of patients (79%) did speak with someone prior to seeking care in the ED and that was most often a family member (77%). Fewer patients spoke with their physician (15%) or nurse line (15%). The most common reason patients gave for seeking care in the ED was that their condition was an emergency (72%). Patients also stated they were influenced by no appointment needed (28%), unable to get appointment or their clinic was closed (27%), preferred to go to ED (24%), and able to get a ride to ED (19%).
Discussion The majority of patients interviewed reported they were in the ED because they thought their condition was an emergency. Patients do discuss their health conditions with others prior to going to the ED, but most do not consult health care personnel. Since most patients named a clinic as their usual source of care, informing patients that they can call the clinic or a nurse line for medical advice during and after business hours may reduce the number of nonemergent ED visits. In addition, clinics can advise patients to seek care at EDs where the clinics’ physicians have
Downloaded from jpc.sagepub.com by guest on November 19, 2015
136
Journal of Primary Care & Community Health 6(2)
admitting privileges to improve continuity of care and access to electronic health records. An important finding is that the majority of patients believed their condition was an emergency yet a third of them were unable to be seen in their clinic because of a lack of appointment availability or the clinic was closed. Also, a third of responders reported they had talked to their physician or a nurse prior to going to the ED. These findings suggest a need to re-evaluate concerns about ED use and consider the positive role of the ED as a safety net for clinics who do not have the capacity or cannot be open 24 hours a day. This study is limited by the small number of patients interviewed but is enhanced by receiving all of the ED patients’ claims data. Future studies could include interventions at clinics to inform their patients of the availability of medical personnel after hours to determine the necessity of an ED visit. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Pitts SR, Pines JM, Handrigan MT, Kellermann AL. National trends in emergency department occupancy, 2001 to 2008:
effect of inpatient admissions versus emergency department practice intensity. Ann Emerg Med. 2012;60:679.e3-686.e3. 2. Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Rep. 2008;(7):1-38. 3. Baker LC, Baker LS. Excess cost of emergency department visits for nonurgent care. Health Aff (Millwood). 1994;13: 162-171. 4. Garcia TC, Bernstein AB, Bush MA. Emergency department visitors and visits: who used the emergency room in 2007? NCHS Data Brief. 2010;(38):1-8. 5. Flores-Mateo G, Violan-Fors C, Carrillo-Santisteve P, Peiro S, Argimon JM. Effectiveness of organizational interventions to reduce emergency department utilization: a systematic review. PLoS One. 2012;7(5):e35903.
Author Biographies Ann Curoe is a Clinical Research Associate at the Medica Research Institute. Dr. Curoe is a family physician with a research interest in outpatient primary care. John Kralewski is a Senior Research Fellow at the Medica Research Institute and a Professor Emeritus, School of Public Health, University of Minnesota. Dr. Kralewski’s research focus is organizational factors influencing the cost and quality of care provided by medical group practices. Megan Savage is a Research Informatics Analyst at the Medica Research Institute. Ms. Savage has a background in biomedical engineering and informatics. Beth Lindholm is the Lead Research Analyst at the Medica Research Institute. Ms. Lindholm has a background in nursing and informatics.
Downloaded from jpc.sagepub.com by guest on November 19, 2015
research-article2014
JPCXXX10.1177/2150131914551986Journal of Primary Care & Community HealthCuroe et al
Research Letter Journal of Primary Care & Community Health 2015, Vol. 6(2) 134–136 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131914551986 jpc.sagepub.com
A Day in the Life of an Urban Emergency Department
Ann Curoe1, John Kralewski1, Megan Savage1, and Beth Lindholm1
Abstract Importance: The annual number of patient visits to emergency departments (EDs) continues to increase. Patients seen in the ED for nonemergent conditions potentially increase the cost of health care and lead to overcrowding in EDs. Objective: To gain insights into the factors leading to nonemergent use of hospital EDs. Design, Setting, and Participants: During a 24-hour period, we interviewed 67 patients in an urban ED. A total of 232 patients were seen in the ED and the hospital provided all claims data. Intervention: None. Main Outcomes and Measures: Elicit and record patient-stated reasons for seeking care in the ED. Results: Interview results showed that 90% of patients had a primary care clinic although 23% of those clinics were not affiliated with the hospital. Of the 67 interviewed patients, 72% reported they came to the ED because their condition was an emergency, 79% had spoken to someone prior to going to the ED, but only 30% consulted medical personnel. Conclusions and Relevance: Patients did not go to the ED because they lacked a primary care clinic. Most patients did not discuss their condition with medical personnel prior to going to the ED. Informing patients of clinic and hospital affiliations may improve continuity of care and access to electronic health records. Keywords access to care, emergency visits, primary care, managed care, patient-centeredness
Introduction The increasing use of emergency departments (EDs) for nonemergent visits is overcrowding these facilities and potentially increasing the cost of care.1-3 While the magnitude of ED use has been well documented, little is known about the factors influencing these use patterns and even less is known about effective interventions.4,5 Our study was designed to contribute to a better understanding of the factors influencing these use patterns by conducting indepth interviews with patients and documenting the demographic characteristics and insurance status of these patients.
Methods Study Sample This study was conducted at an urban hospital and was approved by the hospital’s institutional review board. On a week day over a continuous 24-hour period trained interviewers were in the ED. Patients were seen initially by a physician and/or a nurse. Patients who were medically or psychiatrically unstable, intoxicated, demented, or who did not speak English were not interviewed. Parents or guardians were asked to answer the questions for those younger than 18. Those patients participating in the study received
a $10 gift card. During the 24-hour period, 232 patients were seen in the ED and 67 (29%) were interviewed. The hospital provided deidentified demographic data, reason for visit and facility and professional payment claims for all of the patients. To protect patient privacy, we did not link patient interview responses to the data provided by the hospital.
Study Design The interviewers asked patients if they had a usual source of care, how often they sought medical care in the past 12 months, if they consulted anyone prior to going to the ED, health insurance status, educational level, and age. The interviewers also asked patients to tell them some of the reasons why they came to the ED. After patients answered this openended question, they were asked if in addition any of the following influenced their decision: no appointment needed, transportation availability, inability to get an appointment at 1
Medica Research Institute, Minnetonka, MN, USA
Corresponding Author: Ann Curoe, Medica Research Institute, Mail Route CW105, PO Box 9310, Minneapolis, MN 55440-9310, USA. Email: [email protected]
Downloaded from jpc.sagepub.com by guest on November 19, 2015
135
Curoe et al Table 1. Patient Interview Responses. Age, years Percentage Educational level Percentage Health insurance Percentage Type of insurance Percentage Clinic as usual source of care Percentage Clinic is affiliated with hospital Percentage Number of ED visits previous 12 months Percentage Spoke to someone prior to going to ED Percentage With whom did you speak Percentage Reason for ED Visit
5
10
9
Nurse line
Insurance provider 1 Prefer to go to ED
Able to get a ride to ED
24
19
15 Unable to get clinic appointment or clinic is closed 27
>65 18
Abbreviation: ED, emergency department.
their clinic, preferred to receive care in the ED, or because they thought they had a medical emergency.
Results During this 24-hour study period, 91% of the 232 patients seen in the ED had health insurance. Almost half had Medicaid coverage (45%), 30% had employer-based health insurance, 25% Medicare, and less than 10% were uninsured. The patients were distributed across all age groups 65 years (19%). Females comprised 52% of the patients and 47 (20%) patients were admitted to the hospital. Table 1 shows that the 67 patients interviewed were similar to the overall 24-hour patient population in terms of age 65 years (18%). The patients interviewed had a similar insurance status to the entire patient population with 38% covered by Medicaid, 38% by employer-based plans, 23% by Medicare, and 13% uninsured. Most patients (90%) listed a clinic as their usual source of care although 23% of these patients listed a clinic whose
providers do not have privileges at this hospital. The majority of patients (79%) did speak with someone prior to seeking care in the ED and that was most often a family member (77%). Fewer patients spoke with their physician (15%) or nurse line (15%). The most common reason patients gave for seeking care in the ED was that their condition was an emergency (72%). Patients also stated they were influenced by no appointment needed (28%), unable to get appointment or their clinic was closed (27%), preferred to go to ED (24%), and able to get a ride to ED (19%).
Discussion The majority of patients interviewed reported they were in the ED because they thought their condition was an emergency. Patients do discuss their health conditions with others prior to going to the ED, but most do not consult health care personnel. Since most patients named a clinic as their usual source of care, informing patients that they can call the clinic or a nurse line for medical advice during and after business hours may reduce the number of nonemergent ED visits. In addition, clinics can advise patients to seek care at EDs where the clinics’ physicians have
Downloaded from jpc.sagepub.com by guest on November 19, 2015
136
Journal of Primary Care & Community Health 6(2)
admitting privileges to improve continuity of care and access to electronic health records. An important finding is that the majority of patients believed their condition was an emergency yet a third of them were unable to be seen in their clinic because of a lack of appointment availability or the clinic was closed. Also, a third of responders reported they had talked to their physician or a nurse prior to going to the ED. These findings suggest a need to re-evaluate concerns about ED use and consider the positive role of the ED as a safety net for clinics who do not have the capacity or cannot be open 24 hours a day. This study is limited by the small number of patients interviewed but is enhanced by receiving all of the ED patients’ claims data. Future studies could include interventions at clinics to inform their patients of the availability of medical personnel after hours to determine the necessity of an ED visit. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Pitts SR, Pines JM, Handrigan MT, Kellermann AL. National trends in emergency department occupancy, 2001 to 2008:
effect of inpatient admissions versus emergency department practice intensity. Ann Emerg Med. 2012;60:679.e3-686.e3. 2. Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Rep. 2008;(7):1-38. 3. Baker LC, Baker LS. Excess cost of emergency department visits for nonurgent care. Health Aff (Millwood). 1994;13: 162-171. 4. Garcia TC, Bernstein AB, Bush MA. Emergency department visitors and visits: who used the emergency room in 2007? NCHS Data Brief. 2010;(38):1-8. 5. Flores-Mateo G, Violan-Fors C, Carrillo-Santisteve P, Peiro S, Argimon JM. Effectiveness of organizational interventions to reduce emergency department utilization: a systematic review. PLoS One. 2012;7(5):e35903.
Author Biographies Ann Curoe is a Clinical Research Associate at the Medica Research Institute. Dr. Curoe is a family physician with a research interest in outpatient primary care. John Kralewski is a Senior Research Fellow at the Medica Research Institute and a Professor Emeritus, School of Public Health, University of Minnesota. Dr. Kralewski’s research focus is organizational factors influencing the cost and quality of care provided by medical group practices. Megan Savage is a Research Informatics Analyst at the Medica Research Institute. Ms. Savage has a background in biomedical engineering and informatics. Beth Lindholm is the Lead Research Analyst at the Medica Research Institute. Ms. Lindholm has a background in nursing and informatics.
Downloaded from jpc.sagepub.com by guest on November 19, 2015
