Study tallies cost of growing reliance on emergency care

In the latest snapshot of the nation's health, which this year highlights emergency department use, the Centers for Disease Control and Prevention found that one in five Americans visited an emergency department at least once in 2011.

The report, “Health, United States, 2012,” showed that the number of ED visits has increased 34% from 97 million in 1995 to 130 million visits in 2010. The exact number of emergency department visits in 2011 wasn't stated. Highest use in 2011 was among children younger than 6 (24%) and adults 75 and over (27%) (link).

Andrew Sama, MD, president of the American College of Emergency Physicians, said the numbers show a growing dependence on EDs by patients and even primary care doctors, who he said are instructing patients to go directly to the ED when they need complex tests for potentially serious problems or when patients need immediate help outside medical office hours. Dr. Sama is senior vice president of emergency services at North Shore-Long Island Jewish Health System in Manhasset, N.Y.

Among other findings:

• In 2009-10, 81% of emergency department visits were discharged for follow-up care; 16% ended with the patient being admitted to the hospital; 2% ended with the patient leaving without completing the visit; and less than 1% ended in death.
• Those with Medicaid coverage were more likely than the uninsured and those with private insurance to visit the ED at least once in the past year.
• Injuries were the primary reason adults visited the ED.
• Between 2000 and 2010, 35% of emergency visits included x-rays. Use of computed tomography scans and magnetic resonance imaging, more than tripled from 5% to 17% of ED visits in that period.

Dr. Sama said the sharp rise in use of CTs and MRI in emergency department visits reflects an increasingly complex patient population and the expectation from patients and doctors that problems will be diagnosed quickly and definitively in the ED.

“Many people who would have been hospitalized in the past are going home or being put into observation,” he said. “That's why you're seeing advanced imaging increase in emergency centers.”

After-hours primary care

Round-the-clock access is another reason patients go to EDs, Dr. Sama said. A study in the January Health Affairs presented evidence of the effect on ED use when patients have trouble contacting their primary care doctors. Patients with consistent sources of care who reported difficulty reaching their physicians after hours (21%) were much more likely to come to the ED (37.7% vs. 30.4%) than those who had fewer problems seeking medical help after hours (link).

But with the increased dependence on EDs and fewer emergency departments nationwide (down 11% from 1995-2010) come longer waits, the CDC report said. Wait times to see an emergency doctor went from 45 minutes in 1998 to 2000 to 55 minutes in 2008 to 2010.

Costs of emergency care also increased 77% in the decade from 2000 to 2010, when the mean price of care (adjusted for inflation using 2010 dollars) for an ED visit that did not result in hospitalization went from $546 to $969.

What is often misrepresented in discussions of the expense of ED care, Dr. Sama said, is the percentage of health care costs ED care represents. The CDC report found that emergency department care makes up only 4% of total health care costs in the U.S.