Emergency doctors say study overestimates avoidable ED visits

A Massachusetts report suggests that expansions in primary care access are necessary.

By Jennifer Lubell — Posted Sept. 17, 2012

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A Massachusetts cost trends study concluding that preventable visits accounted for roughly half of all emergency department volume in 2010 isn’t presenting a fully accurate picture of ED use in the state, according to the American College of Emergency Physicians.

The Massachusetts Division of Health Care Finance and Policy said the avoidable visits demonstrate an inefficient use of ED resources and that the system needs to expand primary care access and modify patient behaviors. ACEP contends that the state has been using an outdated formula to track ED utilization trends that overinflates the numbers of nonemergent or avoidable visits by looking at final patient diagnoses instead of symptoms.

The Massachusetts study also is limited in that it focuses only on discharged patients, not admissions, said Peter Smulowitz, MD, an emergency physician at Beth Israel Deaconess Medical Center in Boston who serves on ACEP’s state legislative-regulatory committee. “I don’t think it’s fair to say 50% of cases are not emergent when there are a number of cases that are admitted to the hospital.”

To determine utilization trends for ED outpatient visits, the Massachusetts health care division drew from a formula developed by John Billings, an associate professor at the Robert F. Wagner Graduate School of Public Service at New York University. The formula looks at three categories of ED visits that could have been prevented through earlier primary care interventions: nonemergent, emergent but treatable by primary care, and emergent but preventable/avoidable.

In fiscal 2010, Massachusetts clocked in 2.4 million outpatient ED visits, with avoidable or preventable visits making up 49% of that volume. Most of these visits were in the nonemergent or primary care-treatable categories. From 2006 to 2010, the total costs of avoidable ED visits increased by 35.4%, while the average costs per visit for these categories rose by more than 27%.

The study found that most outpatient ED visits were taking place at times when regular health care services weren’t accessible. Those receiving care in the ED during regular office hours for avoidable conditions may have had other primary care access problems or sought out the ED as a convenience, the study said. Seeking emergency care for preventable conditions was especially prevalent among certain populations, such as the uninsured, women, children and minorities.

It’s telling that these findings came from Massachusetts, said Perry Pugno, MD, MPH, a family physician and vice president for education with the American Academy of Family Physicians. Since implementing a near-universal coverage requirement in 2006, the state is facing a variety of issues that expanded coverage eventually will create for the rest of the country, he said. “If everyone has an insurance card, they’re going to look for primary care resources, and the shortages [in primary care] are going to become even more apparent than they are right now.”

People use the ED for primary care problems if they can’t see their regular physicians, but it’s a very expensive and inefficient way to obtain care, Dr. Pugno said. The facility may end up spending a lot on tests and treatments because it is unfamiliar with a patient’s medical history, which “makes a huge difference for patients and the effectiveness of treatment,” he said.

Expansion of coverage and delivery reforms in the state appear to be helping somewhat to tamp down the overall growth in ED use, despite the reported increases in volume since 2006. But to improve access further and divert more people away from the ED for nonemergencies, the study recommended policies to improve the availability of primary care, such as extending physician office hours.

But Dr. Smulowitz’s research suggested that preventing nonemergent cases from ending up in the ED wouldn’t necessarily save much money. In comparing less urgent categories of ED visits with more complex ones, he and his co-authors found that “the overall cost savings for all of the categories of visits for the less urgent categories under optimal circumstances was about 0.2% to 0.8% of total health care expenses.” The findings of that study appeared in the July Annals of Emergency Medicine.

The state understandably wants to cut costs in making these recommendations, but “the real cost savings in the long run is to keep patients out of the hospital, where the big bills accrue, and helping to manage chronic disease better,” Dr. Smulowitz said.

To determine the appropriateness of ED use, Massachusetts also has misused an algorithm that was intended to track developments that bolster the primary care safety net in states, Dr. Smulowitz said. The algorithm was developed in an urban New York population and never has been tested in other communities to see if it matches up properly, he said. In addition, he said, it overestimates the number of nonemergent and emergent treatable primary care conditions by categorizing cases based on diagnosis.

For example, a patient may present with crushing chest pain, a potential symptom of a heart attack, but be discharged with the nonurgent diagnosis of heartburn. “To the patient, this was clearly an emergency,” he said. ACEP has noted that some state Medicaid officials have been using the algorithm to deny coverage for ED use based on final discharge codes for diagnoses.

ACEP has advocated for recognition of the “national prudent layperson standard,” ACEP President David Seaberg, MD, said in a statement. That standard requires insurers to base coverage on whether a person without medical training reasonably should have considered his or her symptoms to be signs of an emergency.

Dr. Smulowitz said ACEP has approached Massachusetts about the use of Billings’ algorithm. “I don’t know why they continue to use it, but I do hope & as we continue to work with them over time, they will see this is not the right approach.”

The Massachusetts Division of Health Care Finance and Policy responded that final diagnosis does play a role in the formula’s determination of whether a certain condition could have been prevented. However, “it also relies on severity as coded by the intake provider as an indicator of how ‘urgent’ a given patient’s presenting complaint was,” according to a statement from the division. This gives health care professionals the ability to distinguish, for instance, between a child with a mild fever and one with a high fever.

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Primary care doctors increasing access

In its study on emergency department use, the Massachusetts Division of Health Care Finance and Policy recommended improving primary care access to keep patients from having to seek care in the ED. The American Academy of Family Physicians has reported recent increases in the percentage of members offering longer hours and shorter wait times for patients.

Service 2008 2009 2010
Extended hours 42.4% 43.3% 48.8%
Weekend appointments N/A 32.2% 31.6%
Same-day scheduling 28.9% 62.2% 73.2%

Source: AAFP Practice Profiles, 2008-10

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External links

“A Novel Approach to Identifying Targets for Cost Reduction in the Emergency Department,” Annals of Emergency Medicine, published online July 16 (link)

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