Studies: Minor complaints not driving ED overcrowding, costs

But a tool used to assess this finding may not be accurate for this purpose, and other system factors could be more important.

By Victoria Stagg Elliott — Posted June 4, 2007

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Nonurgent problems are not packing emergency departments beyond their capacity, and reducing the use of this medical service will not much affect the amount of money that is spent by public programs such as Medicaid, according to studies presented at the Society for Academic Emergency Medicine annual meeting last month in Chicago.

This research is the latest to challenge the notion that emergency department overcrowding is primarily the result of uninsured patients using these facilities to care for minor health issues that could be dealt with in primary care or other settings.

"It's a myth," said Linda Lawrence, MD, president-elect of the American College of Emergency Physicians. "We do see nonurgent issues because people do not have anywhere else to go, but they do not cause the ED to be crowded. They're straightforward, in-and-out sort of patients."

ED overcrowding is a long-recognized problem. An American Medical Association report issued in November 2006 found the emergency/trauma care system to be at a "crisis point." The organization's policy calls for expansion of the emergency health care system capacity and triage systems that can direct patients to appropriate health services based on symptoms.

Experts suggest that these recent studies, along with previous ones, indicate that the problem is not just a result of what goes on in the emergency department. The entire health care system plays a role, and trouble in this one area is a sign of challenges elsewhere.

"The ED is a window into access to care, and when you improve care outside the ED, people come to the ED less," said Robert Lowe, MD, MPH, director of the Center for Policy and Research in Emergency Medicine at Oregon Health & Science University in Portland.

One paper found that reducing emergency department use by participants in the Oregon Health Plan -- that state's expanded Medicaid program -- would do little to change the overall amount of money spent on the program. Researchers analyzed the cost of medical services received in the emergency department that did not lead to hospitalization, finding that policies that reduced this rate by 25% most likely would result in lowering expenditures by only 2%. The authors suggest that strategies targeting the 11% of enrollees who account for 50% of emergency department expenses most likely would result in a bigger payoff for less effort.

"There's this perception that people on Medicaid use the ED a lot, particularly for nonurgent things. There is not really any evidence to support this one way or another," said Daniel Handel, MD, MPH, lead author on the paper and a health services research fellow at Oregon Health & Science University. "People are somewhat reasonable, and they don't want to increase this kind of cost."

Another study challenged the ability of the "emergency department algorithm," a tool meant to assess access to care, to determine the proportion of visits that could have been handled in other types of health care facilities -- something for which this formula is often applied. The authors attempted to use the algorithm to determine if it could detect changes in the types of emergency department visits before and after cutbacks in the Oregon Health Plan. Despite significant increases in the total number of people using emergency services, it was not able to detect changes in nonurgent visits.

"It's designed to measure access to care. It's not intended to question an individual's decision-making. That's not what the developer of the algorithm had in mind, but we have seen it used in these contexts," said Dr. Lowe, the paper's lead author.

A third study found evidence that proximity also might play a role in the type of health service used.

This paper, also from Oregon, found that children who lived more than a mile from an emergency department had an 11% reduced usage rate compared with those who lived less than a half a mile from this type of health facility.

Those who lived between 1½ miles and 3 miles from their primary care physicians used the ED 13% more than those who lived less than three-quarters of a mile away, the study said. The authors urged that distance be taken into account when health plans assign families to primary care physicians.

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External links

Society for Academic Emergency Medicine annual meeting abstracts, Academic Emergency Medicine, May (link)

Society for Academic Emergency Medicine, annual meeting, May 16-19, Chicago (link)

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