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News: Beating the 80-20 Rule in the ED

Carter, Kelly MD

doi: 10.1097/01.EEM.0000428619.39205.78

Dr. Carteris an emergency physician at Johnston Memorial Hospital in Abingdon, VA, and an assistant professor and clinical faculty member in emergency medicine at Edward Via College of Osteopathic Medicine in Blacksburg, VA. She is a founder and a CEO of Brily Innovations.



I used the 80-20 rule in medical school. It was a secret strategy if you were asked a percentage question by the attending. You answered 20 percent if you thought it was unlikely and 80 percent if it was more likely. A different 80-20 rule works in economics known as Pareto's Principle. Italian economist Vilfredo Pareto observed in 1906 that 20 percent of the people in Italy owned 80 percent of the wealth. (See FastLinks.) That applies to the wealth distribution in the United States in 2007, too, with 20 percent of the population owning 85 percent of the wealth. (See FastLinks.)

It is said in business that 80 percent of your profits comes from 20 percent of your customers, and this applies to medicine as well. Twenty percent of the population incurred 80 percent of the health care expenses in 2004. (See FastLinks.) One percent of the population generated 22 percent of the health care expenses. Apply this to your emergency department; is it possible that one percent of your ED population generates 22 percent of the charges? Our numbers showed that five percent of our ED patients accounted for 22 percent of our annual visits in 2010-2011. We found on chart review that there were duplicate workups, unnecessary tests, preventable admissions, and a lack of coordinated care. Perhaps the time has come for us as emergency physicians to recognize the full impact our actions can have in these populations and on the overall economics of health care.



My business partner and fellow emergency physician, Brian Dawson, MD, and I created a program, Align, to hold our own department accountable for our top ED visitors. We identified barriers such as illiteracy, lack of transportation, and need for a primary physician or pain management specialist. We created premade care plans addressing the individual needs of each frequent patient in collaboration with their own specialists, primary care physicians, and our emergency physicians. These care plans are delivered instantly and electronically to the physician when they sign up for the patient. Our follow-up nurse is automatically notified of their visit, and will call patients after ED discharge to arrange follow-up and review discharge information.

She also contacts the inpatient case manager to optimize discharge planning if the patient is admitted. These patients are called on a regular basis, and the lines of communication remain open with their primary providers. By recognizing these patients on arrival as our managed population and tailoring our care to their unique needs, we have seen a 55 percent reduction in visit counts and a 60 percent reduction in charges. We also found that these patients now spend less time in our ED when they do visit; visits are 27 percent shorter on average. We no longer have to spend our valuable time reviewing previous CT scans and discharge summaries. This awareness of the patients' past, present, and future health care needs has led to greater satisfaction for our patients and our providers, and limited some frustrating encounters.

Our program is set up to identify patients as they become frequent visitors so we are proactive in managing this unique population. Initially, we chose the top 25 visitors over one year, and we now add patients when they reach a threshold of more than three visits in one month or six visits in four months, which would qualify the patient as a “highly frequent emergency department user.” (Ann Emerg Med 2012 60[1]:24.) We practice in a small hospital of 112 beds in a small town with 7,000 people with a relatively busy ED with 29 beds and slightly more than 40,000 annual patient visits. We have improved our distribution since deploying Align: five percent of our patients now make up 17 percent of the visits, down from 22 percent. Think of the impact we could have if each of our departments managed our frequent visitors with greater awareness.

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