Which of the following strategies do you think would be most successful at reducing ED use? Prehospital diversion, patient education, or adding ED capacity? The surprising answer, according to a study that recently appeared in Academic Emergency Medicine, is patient education.
A systematic review of the published literature on interventions to reduce ED use by a multi-institution team of researchers revealed that patient education initiatives yielded decreases in ED use ranging from 21 percent to 80 percent. (Acad Emerg Med 2013;20:969.) Prehospital diversion, in comparison, only resulted in drops of three percent to seven percent. The most surprising of all, some studies showed that adding ED capacity reduced use from nine percent to 54 percent, but one study found increased use of 21 percent, perhaps as a result of greater supply causing higher demand.
Two other less startling interventions also appeared to reduce ED use: managed care and patient financial incentives such as ED copays, coinsurance, or high deductibles. A much larger body of literature is available on these strategies, and nine of 10 studies on patient financial incentives found decreases of three percent to 50 percent, while 10 of 12 managed care studies had decreases ranging from one percent to 46 percent.
“The education piece was a bit of a surprise to us,” says Sofie Rahman Morgan, MD, an assistant professor of emergency medicine at Emory University in Atlanta. “It's a low-tech solution. The studies generally just gave patients or families a booklet on self-care, and in a couple it was complemented with a one-on-one session with a nurse. That's incredibly simple, and something that would probably make people happier with the care they receive, as opposed to a copayment, which leaves a more negative reaction.”
But when the researchers tried to delve further into the outcomes of the interventions, beyond simply the reduction in ED use itself, they found that the studies yielded little insight. “We wanted information on the financial outcomes and the health outcomes of these interventions, and there's very little in the literature,” said Dr. Morgan, adding that only eight of the 39 articles in their review (20.5%) included any cost data. “If the driver behind this is trying to reduce costs associated with ED care, why aren't there studies looking at what cost reductions the interventions achieved? This should be a primary outcome.”
The literature has many other limitations on this topic: almost all the studies are observational, and they are not comparing apples with apples in many cases. Some measured ED visits in total, for example, while others assessed ED visits per user.
“And a lot of the studies, especially the patient education studies, involved pretty small sample sizes,” Dr. Morgan added. “If policymakers and insurers are going to be moving forward to support interventions to reduce ED use, it needs to be an evidence-based movement. In my mind, our review is a first step, assessing what evidence is already out there and where there are gaps in the knowledge. The best approach is probably going to be some combination of these, and what is right may vary by insurer, region, or organization trying to do this.”
Hospitals, insurers, policymakers, and researchers also need to be looking at a much broader question, said Brent Asplin, MD, the chief clinical officer at Catholic Health Partners, Ohio's largest health system, and a former chair of emergency medicine at the Mayo Clinic. “What should be done to most effectively meet the needs of a population for acute unscheduled care? That's not just about ED use, which is too narrow of a question. It's about looking at a whole range of options: primary care, virtual care, urgent care, retail care, and so on,” he said. “How do we structure systems so that we're meeting the patients' needs with the most efficient resource we have available at the time those needs arise?”
Dr. Asplin noted that today's health care system has evolved to meet the needs of providers rather than the needs of patients when it comes to acute unscheduled care. “The traditional approach has been to punish patients after the fact for choosing the wrong venue — ‘it was inappropriate to come to the ED for this, so we won't cover it!’ — rather than making the system as seamless as we can for them,” he said. “If you think about how the rest of our lives work, that's not the way it is. Retail, banking, and other areas of the economy are all about meeting needs in real time. Why would we be surprised that people would start to expect the same from health care?” (Read an EMN article on acute unscheduled care solutions at http://bit.ly/1a1tQac.)
Opportunities for cost savings are there for the taking by care for low-acuity problems in alternate settings, and even greater savings lay in wait for finding safe and reliable alternatives to hospital care and in reducing the variability by which patients get admitted to the hospital. “I'm more interested in looking at the back door to the ED — the decision process for who gets admitted — than the front,” Dr. Asplin said. “We have the opportunity to reduce variation and create safe and preferable alternatives there with a much greater potential for cost savings.”
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