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On "unnecessary" ED visits: background reading

Here are a bunch of very informative pieces on why trying to blame excessive costs or busy-ness on low acuity patients in the ED is, at be...

May 6, 2020

On CNN re: COVID19

I had the opportunity to talk to John King on CNN about COVID-19 in the ER (May 6, 2020) in my first national news appearance.

July 10, 2019

Pre-Reflections on Re-Reading the House of God

The most apt Google Image result labeled for reuse
Some log-rolling: check out the fantastic video* JAMA made: ja.ma/HouseofGod.

I've read the House of God twice: First, as a senior in college, having done some shadowing and research work in EDs (and already accepted in med school) and again after my medicine sub-internship (on the advice of my brother-in-law/EM doc/premed mentor).

My first reaction on my first pre-med school read: OH WOW this is all so bizarre and dehumanizing what did I get myself into?!

My reaction after my med sub-I: yeah that's about right.

I haven't re-read it since then, and am currently planning to (on the library waitlist) so of course all of the grains of salt.

First, to some of the good points: the reasons it initially and still resonates speaks to it's "truth telling." Medicine is a fairly unique field for a number of reasons, including the dehumanizing nature of (particularly) hospital-based medical training, as well as the re-humanizing nature of the privilege I have in putting on pajamas and helping people who are usually some combination of sick and scared; I am rather well-paid to be let into their lives.

To some of the... less good points: there are a lot of sexist and probably racist aspects of/in the book; I haven't read the book in 12 years, and I am a pretty privileged cis-het white male, and I still remember a bit of that. The easy excuse is "well of course a book written 4 decades ago--known for its truth telling--is not very PC!" but perhaps, if nothing else, it reflects the sexism and racism that permeated medicine then and still do now. I'm not letting the book off the hook but I guess at the bare minimum that is where we were and where we are.**

I was speaking with some coworkers about it and one of them described The Fat Man in a way which I think applies well to the book as a whole: it is easy to see him only through his shallow cynicism, but it doesn't take much to see that he is trying to reach a deeper humanity in a very cynical world.

My favorite of the laws--Law #4--is similarly a microcosm of this. "The patient is the one with the disease" can mean a lot of things. It is a good reminder both for professional wellness--no matter how bad my shift, I was paid to be here, and I get to go home at the end. And, it's a nice reminder that we're here *for* the patients, to help them, as they are the one with the disease. (I wrote about some of this previously Who is the Poor Historian? in EP Monthly).

I'm looking forward to rereading largely because I'm curious how much my memory holds up and how much my perspective has changed.

Lastly, I will repeat my oft-repeated opinion that the hands-down most accurate portrayal of what it's like to work in a hospital is Scrubs.

*and outstanding hyperlink. For the record I did not work on this at all, but I do get to work with the amazing people who made this video on JNO Live.

**I don't mean to be too cynical but I would not be surprised if I need to edit and update this paragraph after people much smarter and better able to speak to these issues give me much needed feedback.

April 5, 2018

Pick a Scalpel, Any Scalpel

I've always found the scalpel numbering system unintuitive. Here's how I remember which is which:
#10 has a big curve, like a 0.
#11 is pointy, like the fallen 11.
#15 has a small curve, as only part of a 5 is curved.

January 29, 2018

The Prudent Layperson Standard OR How I Learned to Keep Worrying About Anthem Breaking the Law

UPDATE 3/1/18: this post is now expanded into an article at EPMonthly:  Prudent Layperson, Meet Imprudent Payer

This is taken from my twitter thread on the prudent layperson standard which was in response to this article by Sarah Kliff in Vox on Anthem denying claims for ER visits based on final diagnoses.

The ACA made the prudent layperson standard federal law (ACEP piece). The prudent layperson standard is exactly what it sounds like: the definition of a medical emergency is that a normal person with an average knowledge of medicine thinks is an emergency -– the patient’s symptoms make it an emergency, not the final diagnosis. So severe abdominal pain that turns out to be “just” an ovarian cyst is, by definition, an emergency.

This is both obvious and good: the patient can’t tell if their severe abdominal pain is something terrible and dangerous like appendicitis or something that’s painful but not dangerous.

Notably: *severe pain alone* is by law a medical emergency.
[That's the case in the Vox article]. Here’s the rule if you’re interested:
Oh and it’s written into the legislation, too:
In fact, most states (32+DC) had state prudent layperson standards well before the ACA made it federal, including Indiana [where the case in the Vox article took place] [UPDATE 2/13/18: according to this article, 47 states + DC currently have prudent layperson laws.]

And once again, this is very important because we shouldn’t expect people to sit at home and worry about whether their severe pain is “just a cyst” or a ruptured appendix or an ovarian cyst causing an ovarian torsion or massive internal bleeding.

If the patient is acting like a “prudent layperson” and thinks they are having an emergency, then it is an emergency and the insurer has to cover the ER visit. Full stop.

This is really important because there is a huge overlap in symptoms between simple benign problems (ovarian cyst) and serious life threatening problems (appendicitis) -- see this fantastic paper by Maria Raven et al.

Anthem is breaking the law by denying claims based on final diagnoses in cases like this and it is terrible and people will get seriously hurt.

Tons of patients end up with final diagnoses like “acute viral bronchitis” which sound simple. Except when the patient is 80 and has CHF and COPD and it could easily be flu or pneumonia or a serious COPD or CHF exacerbation any or all of which could kill them.

See my previous post with a bunch more resources on how worthless and dangerous it is to try to decrease “unnecessary” ER visits.

UPDATE 2/17/18: Consumer Reports just published a piece on a patient getting denied ED coverage for severe headache that turned out to be "just" mastoiditis. 

November 14, 2017

On "unnecessary" ED visits: background reading

Here are a bunch of very informative pieces on why trying to blame excessive costs or busy-ness on low acuity patients in the ED is, at best, a misguided effort:

1) Great overview of many systemic issues which funnel patients to emergency departments, by Annals of Emergency Medicine Editor in Chief Mike Callaham*:
The Prudent Layperson’s Complicated and Uncertain Road to Urgent Care

2) We can't discern low acuity diagnoses from chief complaints, by Maria Raven, Robert Lowe, Judith Maselli, and Renee Hsia in JAMA:
Comparison of Presenting Complaint vs Discharge Diagnosis for Identifying “ Nonemergency” Emergency Department Visits and accompanying editorial by my (now) chair:
some intuitive, oversimplified, yet enduring beliefs about nonurgent patients in the ED should be abandoned. Trying to discern low-acuity conditions and putting up barriers to receiving care or denying payment after receiving care will work no better in future generations than in the past. Attention should be redirected away from penalizing patients, physicians, or hospitals when a condition turns out to be minor. Instead, the emphasis should be on integration across sites of care, especially for the most complex and most expensive patients.
and from his response to a Letter:
The reasons people visit the ED for care are often rational and understandable, driven by a perceived need for immediacy of treatment and lack of an accessible alternative. Many conditions treatable in primary care that are cared for inside EDs in the United States may reflect problems with alternative access to rather than inappropriate actions by the patient.
3) Low acuity ED visits is just not where the money is, by Peter Smulowitz, Leah Honigman and Bruce Landon, in Annals of EM:
A novel approach to identifying targets for cost reduction in the emergency department.

4) EDs aren't overcrowded because of low acuity patients; we are busy because of boarding -- patients we have seen & admitted in the ED and are waiting for their inpatient beds. (tons on this, here's one on how boarding-> crowding in Annals by Brent Asplin et al A conceptual model of emergency department crowding, and 2 of my blog posts 4A) here and 4B) here and 14 below)

5) And for those who suggest higher patient copays for low acuity ED visits, the famous RAND HIE, which shows that patients who have to spend more out of pocket decrease *all* care, both appropriate & inappropriate care (which isn't surprising, given Raven's study, above):

Here are a few studies that show that retail clinics tend to *increase* rather than decrease overall utilization (suggesting something like supply induced demand) and fail to lower (and probably increase!) ED use:
6) Why Retail Clinics Do Not Substitute for Emergency Department Visits and What This Means for Value-Based Care by Jesse Pines in Annals
7) Retail Clinic Visits For Low-Acuity Conditions Increase Utilization And Spending by J Scott Ashwood, Martin Gaynor, Claude Setodji, Rachel Reid, Ellerie Weber, and Ateev Mehrotra in Health Affairs. From what I hear from people who run EDs which opened urgent cares etc, the same holds true, but I don't have great data on that.

UPDATE 12/5/2017
8) Surprise! Uninsured people don't use the ED any more than those with insurance; rather, they use it the same. But, they use other health care less. By Ruohua Annetta Zhou, Katherine Baicker, Sarah Taubman, and Amy Finkelstein in Health Affairs:
The Uninsured Do Not Use The Emergency Department More—They Use Other Care Less

UPDATE 12/18/2017 & 12/25/2017
9) Another great new paper from Maria Raven and Faye Steiner: 1 in 4 patients in the ED were referred from an outpatient provider (and they're more likely to be admitted than other ED patients):
A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization

10) and while finding (9) I found this great review by Maria Raven et al in Annals showing ED visit reduction programs generally don't work:
The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review

11) another British review showing putting "unscheduled care centres (UCC)" in the ED doesn't solve much, by Shammi Ramlakhan, Suzanne Mason, Colin O'Keeffe, Alicia Ramtahal, Suzanne Ablard in EMJ
Primary care services located with EDs: a review of effectiveness

12) This great episode of EM Over Easy on fundamental attribution error
13) David Foster Wallace's This Is Water.
The basic idea: when I cut someone off in traffic, I make excuses for myself (I'm late to work, the light is changing, etc etc) but when someone cuts me off, of course I think they're just a jerk. The less I judge patients for being in the ED, the less stress I have.

14) And here are my 2 blog posts on crowding:
A Spoon in the Bucket?
Empty the Dishwasher

UPDATE 1/29/2018
See my twitter thread on the prudent layperson standard [now here in blog form and here in EP Monthly] which was in response to this article by Sarah Kliff in Vox

15) friendly reminder that the legal definition of a medical emergency is
"a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in... placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; ...serious impairment to bodily functions; ...[or] serious dysfunction of any bodily organ or part.)"

If a regular person with no medical training thinks their symptoms are an emergency, it's an emergency and the insurer has to cover it.

16) it's legislated federal law in the ACA (text)

17) and here is the regulatory version (text)

(for both of these, ctrl+F prudent layperson) to find it

summarized by me here in EP Monthly

18) and before it was federal law for private insurers, it was state law in 32 states + DC (pdf from ACEP)

UPDATE 9/4/2018
19) interesting paper from Sabrina Poon, Jeremiah Schuur, and Ateev Mehrotra analyzing Aetna data:
changes in "low acuity visit" from 2008-2015:
-overall increased by 31% (from 143 to 188 visits per 1,000 members)
-non-ED increased by 140% (from 54 to 131 visits per 1,000 members)
-urgent care increased by 119% (from 47 to 103 visits per 1,000 members)
-retail clinic increased by 214% (from 7 to 22 visits per 1,000 members)
-low acuity ED visits decreased by 36% (from 89 to 57 visits per 1,000 members)
-average overall spending per member increased by 14% (from $70 to $80 per member per year)

[important limitations: single, commercial plan; tough to define what a low acuity visit is (seems to me like their definition gives a useful operational sample, but doesn't define the whole universe of low acuity visits?; and, hindsight bias; and, doesn't look at office-based care; acute unscheduled office care is hard to analyze, etc.]

I have lots of initial thoughts here; mainly, this looks like it didn't save money, we don't know about outcomes, and I think overall this is more about supply-induced demand [funny how non-ED low acuity patients had higher incomes] than meeting unmet demand. But, I also know my priors.

UPDATE 11/26/2018
20) Andy Chou, Suhas Gondi, Olesya Baker, Arjun Venkatesh, and Jeremiah Schuur published a paper in JAMA Network Open** looking at what fraction of patients who could potentially get denied by Anthem's low-acuity ED visit denial policy (see my summary) share symptoms with all ED visitors. No surprises: 15% of patients have diagnoses that might be denied by Anthem; they share symptoms with 87.9% of ED patients.

And a nice accompanying editorial by Maria Raven.

UPDATE 9/23/2020
21) More from Andy ChouSuhas Gondi, Scott WeinerJeremiah Schuur, Benjamin Sommers:
Medicaid expansion associated with only small decreases in ED use among low-income adults--those who reported barriers to care. This is not surprising, as the majority (74%) of low-income adults reported using the ED due to perceived severity of illness. Only 12% came to the ED because clinics were closed, and only 9.5% due to barriers to care. This reinforces that people use the ED because they think they are having an emergency (which is the appropriate and legal definition of an emergency):

Medicaid Expansion Reduced Emergency Department Visits by Low-income Adults Due to Barriers to Outpatient Care

UPDATE 12/1/2020
22) Very nice but obviously frustrating thread by Michael Anne Kyle, a health policy PhD student at Harvard who details her experience trying to get her minor foot injury worked up without, but ultimately only being able to go to the ED:

UPDATE 12/4/2020
23) Didn't realize I never added the paper I wrote with Kao-Ping Chua, Aamir Hussein, Aisha (Liferidge) Terry, Steve Pitts, and Jesse Pines
We looked at what happened to patients in EDs (eg labs, imaging, medications, procedures, dispo) and when (evenings, nights, weekends) and compared what visits theoretically could have been substituted at primary care offices, retail clinics, and urgent care centers based on strict vs very generous estimates of alternative sites' capabilities & hours. Note we did not look at insurance, liability or clinical comfort, or actual ability to schedule an appointment so these are pretty generous estimates (on the other hand some things like some labs or x-rays may have happened more generously at EDs that alternate sites would be fine not doing; but I doubt this would change our results much tbh). 
Based on 2011 NHAMCS we found these strict–generous estimates of how many ED patients had services that theoretically could have been done at alternative sites: "Our criteria classified 5.5%–27.1%, 7.6%–20.4%, and 10.6%–46.0% of visits as substitutable in primary care offices, retail clinics, and urgent care centers, respectively."

UPDATE 4/13/2021
24) Are urgent care visits near an ED associated with lower ED visits? Is adding an urgent care near an ED associated with lower ED visits? Bill Wang, Ateev Mehrotra, and Ari Friedman look at some lower acuity diagnoses visits at EDs & UCCs by ZIP code; they also looked at when a ZIP crossed from <90th percentile in UCC visits to >90th percentile, suggesting a high-volume UCC was opened in a ZIP.

No surprises:
-an increase of 37 lower-acuity urgent care center visits per enrollee was associated with a decrease of a single lower-acuity ED visit per enrollee (54 when excluding the 3 states with the most FSEDs)
-each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs

Obviously not each of these 37 visits would have otherwise been an ED visit; some would have been primary care; many more would not have happened at all (pent-up demand vs supply-induced demand). Regardless, access to UCCs is not magically "fixing" low-acuity ED visits.

*COI: I am was Social Media Editor for Annals which makes made Mike my boss.
**COI: I am Digital Media Editor for JAMA Network Open

November 28, 2016

It's the Medicaid Expansion, Stupid

I came across this nice post:

My initial reactions: hmm, some of this looks like lack of Medicaid expansion, some might be from a combination of too-high premiums/insufficient subsidies/ignorance of subsidies etc on the exchanges.
But wait, "childless adults"? That sounds familiar!

"Childless adults, most uninsured under traditional Medicaid." For those who have studied health policy, it's a stimulus-response, like "chloramphenicol, grey baby" and "dental plan, Lisa needs braces."

I followed the link and noticed the normal, understated citation at the bottom of the post:
Source: Kaiser Family Foundation: Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion?
The title on KFF's page is, not surprisingly:

Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion?

This reminds me of the famous desaturation curve which appears in every airway lecture, as mandated by CMS due to Obamacare:

Note the title of the source of this familiar graph: Critical Hemoglobin Desaturation Will Occur before Return to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine.

(Benumof, Dagg, Benumof. Anesthesiology. 1997 Oct;87(4):979-82.)

How often are these graphs shared without noting their expressed purpose?