How does homelessness affect the utilization of emergency services? Does race influence the risk of violent injury? How can diabetes be diagnosed earlier in ED patients without regular access to health care? Those complex social questions are being posed by the new Andrew Levitt Center for Social Emergency Medicine, a tribute to the work of a pioneer who understood that socioeconomic forces affect patients seeking ED care.
Founded recently at Alameda County Medical Center in Oakland, CA, the center's intentions seem more like the prose inscribed on a certain statue in New York Harbor than it does a medical mission statement. It's a call for more understanding of the poor and underserved, and of the hardships and social factors that bring them to the ED. “One of key goals is to provide an intellectual framework for past, present, and future work exploring the interplay of social forces and emergency care,” explained Harrison Alter, MD, the executive director.
The center is named for the late Andrew Levitt, MD, whose family endowed the center with $400,000, marking the beginning of an institute that, it is hoped, will become a vanguard for “social emergency medicine,” a term coined to reflect its research focus. (http://levittcenter.org.)
How will EDs be affected by health care reform? What are the ways in which they are affected by the lack of primary care access? How can mental health play a role in ED research? These questions typify those the center may help answer. “This is something I spend a lot of time thinking about,” said Dr. Alter. “We are trying to hammer out what domains need to be explored and how to measure them.”
Learning more about the causes of visits to the ED is essential for providing better and more comprehensive care, affirmed Ross Koppel, PhD, a professor of sociology at the University of Pennsylvania. Asthma in children is one example of the interplay between social factors and a medical condition. Living arrangements, access to regular care for monitoring, and exposure to triggers all are “critical determinants,” he pointed out. Study into how these variables can be addressed in ED settings is prescient and practical, he said.
It isn't that such research hasn't been done before, but there is evidence that the center is at the cusp of a growing trend. Four years ago, two Massachusetts emergency physicians — David Morris, MD, and James Gordon, MD, — teamed up to study the role of the ED in homeless and disadvantaged populations and to explore the value of what they called sociomedical care in the ED.
They concluded that EDs caring for these populations had to create more integrated care. (Emerg Med Clin North Am 2006;24:839.) Centers from New York, Chicago, and San Francisco followed suit, publishing evidence that using case managers were associated with fewer visits by repeat ED users and determining how and why opportunities for screening suspected cases of HIV were slipping through the cracks. (AIDS Patient Care STDS 2009; 23:245.)
Last year, investigators at San Francisco General Hospital led by emergency physician Robert Rodriguez, MD, surveyed nearly 200 homeless people in the emergency department to determine what factors brought them to the ED. Many had been without food, shelter, or a safe place for days; on average, these patients spent three nights a week without a bed. These men and women were asked a simple question: Would the availability of alternative sites that provided food and a safe place to stay decrease their use of the ED? Almost a fourth said they would not have made the ED visit if these basic needs had been met. (Ann Emerg Med 2009;53:598.) “This points to a role of the ED as a social welfare institution,” noted Dr. Alter.
“To try to understand the populations [that are] using your emergency room and why is a very good idea,” agreed Mary Ann Baily, PhD, a fellow at the Hastings Center. However, “there may be complexities” in studying such patients, she observed, but there is no question there is a pressing need for such research. Currently, only slightly more than a quarter of all adults ages 18 to 64 report having a regular doctor or source of care, with visits that run on time and with no difficulty contacting their provider by telephone or getting care or medical advice on weekends or evenings, according to the New York-based Commonwealth Fund, a private foundation that conducts independent research on health care.
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