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.
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
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)
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.
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.
21) More from Andy Chou, Suhas Gondi, Scott Weiner, Jeremiah 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):
(Thank you to Kelly Doran for this great summary thread.)
Medicaid Expansion Reduced Emergency Department Visits by Low-income Adults Due to Barriers to Outpatient Care
am was Social Media Editor for Annals which makes made Mike my boss.
**COI: I am Digital Media Editor for JAMA Network Open
**COI: I am Digital Media Editor for JAMA Network Open