Emergency department relief? Keep doctor offices open late
■ Patients often are unaware that evening or weekend appointments are an option, leaving many to view the ED as the choice for face-to-face care.
Primary care physician practices that offer evening and weekend office hours can help patients avoid trips to the emergency department while cutting overall health system spending, suggests an emerging body of research.
A recent study in The Journal of Pediatrics examining the pediatric population confirms what earlier studies among adult patients have found: When patients with urgent health problems have the option to see their regular physician, they will skip ED visits that can involve long waits, big out-of-pocket costs and unneeded testing.
Researchers surveyed more than 800 parents nationwide and found — after adjusting for insurance status, child health, household poverty and educational levels — that the parents getting pediatric care at a practice that was open after 5 p.m. at least five nights a week were half as likely to have taken a child to the ED in the previous year.
Having less-frequent evening hours also made a difference in ED use, the study found. Patients whose pediatrician offices were open late one to four nights a week were 35% less likely to use the ED, while clinics with office hours on at least one weekend day had 11% lower odds of ED use.
“One of the hopes behind having later hours is that people will be able to call or see us rather than go to the ED for things like colds, ear infections, most rashes or ringworm,” said Joseph Zickafoose, MD, the study's lead author. “These are things that, unfortunately, in a lot of urban centers and rural places, they see a lot of people for in the ED.” He also is a clinical instructor in the University of Michigan Medical School's Dept. of Pediatrics and a health researcher at Mathematica Policy Research, both in Ann Arbor.
Dr. Zickafoose's study found no link to lower ED use for other after-hours access services such as phone or email advice. It may be that the kinds of care parents want for their children are matters that require a face-to-face encounter, Dr. Zickafoose said. He added that the effect of later office hours on ED use may be pronounced in the pediatric population.
“Parents tend to be a little more anxious about taking their kids into the ED for things that you could easily talk to them about over the phone,” he said. “It's their kids, and they're going to worry about them.” Adults are more willing to wait for their own treatment, he added.
Less spent on care
Yet studies of adult patients also have results in favor of later office hours in primary care clinics. An analysis of data on nearly 55,000 adults from 2000 to 2007 found that patients whose usual source of care had evening or weekend office hours cost 10% less to care for than those whose doctors kept a 9-to-5 schedule. Extended office hours alone accounted for 42% of the health spending variation among patients, said the study in the September/October 2012 Annals of Family Medicine.
Enhanced patient access, including extended office hours, is a key part of the patient-centered medical home model of care that physician organizations representing pediatricians, family physicians and internists have promoted for several years.
DID YOU KNOW:
45% of family physicians offer either early-morning or late-evening office hours.
“This is definitely a way for patients to feel connected to their physicians, to improve outcomes, decrease costs and be truly patient-centered,” said Reid B. Blackwelder, MD, president-elect of the American Academy of Family Physicians.
The American Medical Association's principles on the patient-centered medical home say enhanced access to care is one of the hallmarks of such a setting. That can include open scheduling, expanded hours, phone consultation and secure email. Payment should recognize the value of physician work associated with after-hours consults and remote clinical monitoring, the AMA's policy says.
It's unclear how many primary care practices offer extended office hours. About 26,000 doctors and other health professionals work at more than 5,700 medical practices that have earned designation as medical homes by the National Committee for Quality Assurance. After-hours access through timely advice via telephone, an electronic messaging system and extended office hours are part of the criteria the committee uses to evaluate how well practices implement the medical-home concept. The NCQA designation can make practices eligible for financial rewards from 36 participating health plans in 26 states and the District of Columbia.
Meanwhile, a 2012 survey of AAFP members found that about 45% offered extended office hours, defined as either early-morning or late-evening hours. Thirty-one percent said they offered weekend appointments.
Schedules sometimes a mystery
In The Journal of Pediatrics study, published online June 4, 28% of parents told researchers that their children's pediatrician's office was not open after 5 p.m., 11% said it offered later hours one to four nights a week, and 12% said it was open late at least five nights a week. Nearly half said their pediatrician offered weekend hours.
A high proportion of parents — 50% — did not know if their pediatrician's office was open at night. That is a problem, Dr. Zickafoose said.
“We need to do a better job of communicating with families about when we are open and about what to do when they need advice after hours,” he said.
Yet even laudable efforts to communicate about extended office hours may not get through, said Geoffrey Simon, MD, chair of the American Academy of Pediatrics' Committee on Practice and Ambulatory Medicine. Before moving to Wilmington, Del., in September 2012, he practiced for more than a decade at an Atlanta clinic with weekend hours that were posted on the door.
“We had Saturday hours almost every week,” Dr. Simon said. “Even after 12 or 15 years, I'd get patients who'd say, 'Oh, I never realized you were open on Saturday.' ”
Increase service, not burnout
Despite widespread agreement that extended office hours can help patients avoid the ED, there are roadblocks to getting it done.
“Those extended hours have a cost,” said David N. Gans, senior fellow of industry affairs at MGMA-ACMPE, an organization of medical practice managers. “You do it for patients' convenience, because it's the right thing for patients, and not necessarily because there's an economic return on investment.”
Later hours could mean more money spent on electricity, clerical staff, nurses and medical assistants. And no one wants the push for expanded access to lead to 16-hour days for doctors, aggravating the pervasive problem of professional dissatisfaction among physicians. Research shows that one in three U.S. doctors meets the criteria for burnout, and one in two reports at least one symptom of burnout. Experts said expanded hours should be accomplished through staggering or otherwise rearranging physician schedules so someone is available to see patients at night or on weekends.
Another option is to hire a part-time doctor, although such arrangements can pose problems in terms of care continuity. Some practices band together to fund extended-hours clinics for several physician groups' patients, or work to form collaborative relationships with urgent care centers that include comprehensive sharing of electronic health records. Each of these alternatives must be studied carefully to ensure that they are financially sustainable, experts said.
“You've got to calculate how many additional patients you would need to see to break even to make it work,” Dr. Blackwelder said. “Perhaps during flu season you've got to do it a bit more, or just before the kids start up sports and need their physicals. You've got be sensible about how you do expand office hours. You can't burn out your practice or your physicians. It's about balance.”
In defense of the ED
Meanwhile, emergency physicians argue that evening and weekend hours at primary care offices eventually reach a point of diminishing returns. They note that most ED use comes from sicker patients who require more care once they arrive at the hospital.
“If I'm a pediatrician and have extended hours, I may be sitting there with my office empty at 10 o'clock at night,” said Alfred Sacchetti, MD, chief of emergency medicine at Our Lady of Lourdes Medical Center in Camden, N.J. “But there's an ER that has to be open anyway in case of emergency, so why not use it for pediatrics patients and use them for extended hours rather than keeping your doors open?”
Dr. Sacchetti suggested that emergency physicians and primary care doctors forge relationships to reduce unneeded testing when patients visit the ED. In some cases, such as in the case of electrical cardioversion for patients with atrial fibrillation, costs are lower at the emergency department than in the cardiologist's office.
But for some physicians, the bottom line is that primary care doctors should expand their accessibility to improve patient care.
“It's time that we in medicine realize that we can't really meet the needs of the patients and their families keeping banking hours,” said Molly Cooke, MD, president of the American College of Physicians. “I don't want to suggest that physicians have been loafing, because that's clearly not the case. But people don't just have problems conveniently between 8 a.m. and 6 p.m., so we really need to be more creative in how we organize our services so people have the care when they need it.”