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Breaking News: Long Suspected but Finally Confirmed: Poor Access Drives ED Visits

Shaw, Gina

doi: 10.1097/01.EEM.0000421862.27634.fe
    Patients endure long waits in emergency departments across the country, like this one at Children's Hospital in Madera, CA, largely because they have poor access to other providers
    Patients endure long waits in emergency departments across the country, like this one at Children's Hospital in Madera, CA, largely because they have poor access to other providers:
    Patients endure long waits in emergency departments across the country, like this one at Children's Hospital in Madera, CA, largely because they have poor access to other providers.

    Some 20 percent of U.S. adults report using the emergency department at least once a year, and everyone had a theory about why they went to the ED instead of a doctor's office or outpatient clinic, but no one had ever formally asked the patients themselves.

    The answers were as many have postulated, but prove for the first time that access to other providers is the major barrier to care. The most common single reason given for coming to the ED was “only a hospital could help” (54.5% of respondents), but when the answers from the National Health Interview Survey conducted by the Centers for Disease Control and Prevention are combined into categories, it becomes clear that far more people are seeking ED care because they lack access to other providers (79.7%), including that their doctor's office was closed, they had nowhere else to go, and the ED is their only provider. (Respondents could give more than one answer, so percentages add up to more than 100 percent.)

    Not surprisingly, when the responses were broken down by insurance status, those without insurance were more likely to say that they had no place to go other than the ED while those with public coverage were more likely to say that they had gone to the ED because their doctor's office or health clinic was closed.

    But people's perception of the seriousness of their illness or injury did not seem to be affected by insurance status, said Renee Gindi, PhD, a survey statistician at the National Center for Health Statistics. “Across the board, whether they had private insurance, public insurance, or no insurance, about half of each category indicated that only the hospital could help them,” she said.

    Nearly half of all people who had used the ED (48%) indicated that they went there because their doctor's office or health clinic was closed. That jibes with the experience of Bon Ku, MD, an emergency physician at Thomas Jefferson University Hospital in Philadelphia who researches ED use patterns. “No one wants to wait in the ED for four, five, or six hours, but patients don't seem to have other viable options,” he said. “Often, they can't get an appointment with their primary care provider for several weeks and can't see a specialist for months.”

    The most common presentations, he said, are those with respiratory complaints or abdominal complaints who are ill but not ill enough to be admitted to the hospital. “They'll say, 'Yeah, I tried to see my doctor, but I can't get in until next week, and I'm coughing all the time and short of breath,'” Dr. Ku said. “Often I'll agree that it really shouldn't wait until next week; they might have community-acquired pneumonia that needs antibiotics right away.”

    A certain percentage of the population — and not just the uninsured — regard the ED as a primary caregiver, Dr. Ku said, particularly those on Medicaid who receive primary care through federally qualified health centers who find the ED more convenient, even with the waits. “The ones in our city provide good care, but there aren't enough of them,” he said. “The wait there can be at least as long as the ED, and at least here they can get an x-ray, medications, and other things that they can't get at the health center.”

    It's much the same in most communities, said Dickson Cheung, MD, MBA, MPH, an emergency physician at Sky Ridge Medical Center in Greenwood Village, CO, and the former chair of the ACEP Quality Improvement and Patient Safety section. “Even people with primary care coverage treat the ED as a primary care provider when they have an urgent complaint because often the true primary care provider can't get them into their schedule. If you have a severe migraine headache, for example, most primary care offices won't be able to see you that same day,” he said.

    What's more, Dr. Cheung said, most primary care offices are not set up for the seamless management of conditions that might need same-day lab work, imaging, IVs, and other services. “Unless the primary care office is connected right to an imaging center or lab facility, the patient has to drive and come back, and if you can't get all that done during office hours, your primary care doc isn't going to stay until 7 or 8 p.m. waiting for test results. The stars really need to align right for that to work, but if the system were better set up so that the primary care providers could arrange these services, patients wouldn't need to go to the ED so much.”

    Some larger health systems are trying to address this problem. WellStar, a five-hospital nonprofit health system with two of the busiest emergency departments in Georgia, has begun opening a series of “health parks” strategically located near population hubs within its five-county service areas. The first, opened in Acworth in July, houses urgent care, diagnostic imaging, preadmission testing, and cardiac and sleep disorder services alongside primary care and specialty physicians' offices.

    But many primary care practices are not affiliated with a large health system that can offer that sort of seamless continuity of care. And as the Patient Protection and Affordable Care Act is implemented, history teaches that primary care physicians will get even busier — and so will EDs. “We can learn from the Massachusetts experience,” said Dr. Ku. “When the individual insurance mandate went into place there in 2006, EDs soon saw an increase in visits because there was a shortage of primary care physicians.”

    Dr. Ku proposed that special funding should be established to enable EDs to provide better continuity care. “EMTALA requires all EDs to screen and stabilize patients regardless of insurance and ability to pay, but we get no funding specifically to carry out that mandate, a unique mandate that no one else has,” he said. “In addition to increased reimbursement for continuity care, there needs to be more and better use of midlevel providers like nurse practitioners and physician assistants.”

    Dr. Gindi said future reports from the CDC using the NHIS data should give EDs even more information to help them gauge usage patterns and plan for patient flow. The new survey questions also include data on time and day of visit (were they at night or on a weekend?) that were not explored in the last report.

    “We would like to use our large sample sizes to look much more closely at why Medicaid patients use the ED and to estimate these patterns state by state,” she said. “We also hope to be able to focus our reports on some condition-specific questions, such as the reasons for ED use among people with asthma, people with cardiovascular disease, and so on.”

    Next year, the “reason for visit” question will also be asked of all ED patients, not just those who were not admitted at their last visit. “We made the assumption that if you were admitted to the hospital from the ED, that it must be strictly a seriousness of condition issue,” Dr. Gindi said. “But we decided we shouldn't make that call. It was certainly a possibility that anyone who had a serious medical problem warranting ED care may also have had no other place to go.”

    The reason-for-visit questions will remain on the NHIS survey through 2013; after that, Dr. Gindi said, supplemental questions like these are subject to the vagaries of funding.

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    • Read the CDC report, “Emergency Room Use Among Adults Aged 18–64: Early Release of Estimates From the National Health Interview Survey,” and others from the NHIS at
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    © 2012 by Lippincott Williams & Wilkins