Patients Often Use ED Even When Primary Care Is Available


As national healthcare reform proceeds, hospitals that have benefited financially from high use of emergency departments (EDs) by routine primary care patients will be challenged to retool primary care delivery and payment methods, according to a research letter published in the February 13 issue of the Archives of Internal Medicine.

Karen E. Lasker, MD, MPH, from the Section of General Internal Medicine, Department of Medicine, Boston Medical Center (BMC) and Boston University School of Medicine, and the Department of Community Health Sciences, Boston University School of Public Health, in Massachusetts, and colleagues analyzed the use of ED services by established primary care patients at BMC, a safety-net hospital, between July 1, 2009, and July 1, 2010. They found that about half of all ED primary care visits took place during weekdays when primary care practices were open and seeing patients.

BMC has 8 primary care practicesemploying 105 primary care physicians (PCPs). During the study period, a total of 39,603 patients had 1 or more primary care visits to BMC. Of those, 65.4% did not visit the ED during the study period; however, 29.8% visited the ED 1 to 3 times and 4.9% visited the ED 4 or more times. Overall the 11,787 patients in the intermediate-use group made 17,759 visits and the 1928 patients in the frequent-use group made 12,289 visits.

The researchers estimate that most ED visits were for low-severity services, based on an analysis of International Classification of Diseases, Ninth Revision, Clinical Modification, codes.

Dr. Lasker and colleagues cited the lack of available PCP appointments as a possible reason for the ED visits during weekdays. At the same time, the practices experienced almost a 25% rate of missed appointments, which often correlates with long wait times for schedule appointments.

“It is possible that patients called the practices with an urgent problem, did not have their telephone call answered promptly, and decided to seek care in the ED instead,” the authors write. Patients abandoned about 13% of their calls to the PCP offices during the study period.

Another possible factor in the use of ED services for low-severity needs is that about a fifth of the primary care services are provided by doctors who have limited availability because of hospital requirements.

Whether changes in practice and payment will reduce high ED usage in this way is unclear, they conclude.

The study was supported by the Department of Medicine at Boston Medical Center/Boston University School of Medicine. Dr. Lasker has disclosed that she was a consultant to Rise Health in 2011.

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