Emergency Departments: Primary Care of the New Century?

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Author: Kenneth K. Chang, MS III
Western University of Health Sciences
AAEM/RSA Education Committee

As aspiring emergency medicine (EM) physicians, what is it that motivates us? Perhaps it was from working as a first responder or in emergency medical services? Or maybe even from shadowing at a busy trauma center or watching a TV show come to life as the ED team rush to diagnose a complex pediatric poisoning? Or maybe, it was a poignant personal experience with serious disease or injury? While these challenging and adrenaline-rush cases provide variety and excitement to the profession, one must always remember that the core of EM is often times primary care medicine. According to the 2014 CDC data, while there were 141.4 million ED visits in the year, only 7.9% of those were critical cases requiring hospital admission.[3] As many as one-third of ED visits are thought to be for primary care complaints.[5] Although there is not a set definition, most of these are defined as non-urgent ED visits, conditions in which a delay of several hours of care would not increase the likelihood of adverse outcomes. In retrospective medical record reviews, non-urgent visits were defined by diagnoses, whether hospital admission was an endpoint, symptoms, and vital signs to name a few. However perceived seriousness of condition by the patient may also be a subjective factor. With changing healthcare policies of our new era, it is inevitable that access to healthcare, especially primary care, will be a significant concern for the younger uninsured and Medicaid population.[4] It is evident that the greatest increase in ED visits between 2006 and 2014 were from the Medicaid population. In that time period, with the exception of injury as the first-listed diagnosis, there has been an increased percentage in medical, mental health/substance abuse, and maternal/neonatal conditions that were managed on an outpatient disposition. From the EM profession’s standpoint, the questions arises: should there be more policy changes and interventions to decrease use of the already overextended ED’s? Or should the EM profession embrace this inevitable change and adapt to care for primary care issues?

 

The overutilization and overreliance of ED’s has been associated with unnecessarily high costs and poor outcomes resulting from gaps in care coordination. A systematic review published in 2011 from Annals of Emergency Medicine found that in three previous studies, introduction of a case management team was effective at reducing ED costs by at least as much as the cost for the team itself. There was support that case management teams have been successful in decreasing ED visits from the most vulnerable population in addition to decreasing homelessness and drug/alcohol use while increasing health insurance coverage and access to primary care physicians (PCPs). It would appear that primary care and ED’s are substitutes for each other, and patients who frequently use the ED are less likely to have PCP’s. It also seems to elucidate that low socioeconomic as well as lower comprehensiveness of care was associated with frequent ED utilization.[1]

However, in a study from Geisinger Health System in Pennsylvania, the results present an opposing perspective. Health plan claims of adults who averaged greater than 1 ED visit within the 2013-2014 year were examined to see if PCP interventions affected ED visit rates. Changes in the primary care delivery system included implementing patient-centered medical homes, financial incentives for PCPS, and redesigning of the primary care system delivery, all in efforts to reduce ED utilization.[6] It was determined that higher rates of multiple ED visits were also associated with higher frequencies of all other health care visits in the same time period, including specialist and PCP offices. This suggests that ED visits are complements rather than substitutes to other health care visits and may be providing unique care that other venues cannot. This implies that frequent ED users may have substantial disease burden such as congenital conditions that requires more health care regardless of access to primary care, and the frequent ED visits are not necessary avoidable.

Perhaps the answer is a combination of both: bringing these primary care interventions to the ED regardless of the patient population and the location. Anson Community Hospital, a rural hospital of Carolinas Healthcare System, for example, has embraced a medical home model that embedded PCPs into EDs so that there is improved coordination of ambulatory care for chronic disease management while simultaneously allowing continuous emergency care.[5] Another suggestion from a recent Annals of Emergency Medicine publication further suggests integrating “Social Emergency Medicine” into medical education to provide physicians with opportunities to collaborate with multidisciplinary teams and provide necessary care. This often includes emergency medicine as a means to supplement not replace outpatient care, for example- HIV patients at an urban setting.[2] Following these models and their positive outcomes, we can look forward to caring for acute conditions and performing critical care procedures all while being comfortable providing interventions to give patients primary care and help with socioeconomic conditions. Only then do we embrace the central theme of EM, caring for anyone regardless of their status or situation.

Works Cited

1. Althaus F., Paroz S., Hugli O., Ghali W.A., Daeppen J.-B., Peytremann-Bridevaux I., Bodenmann P. (2011) Effectiveness of interventions targeting frequent users of emergency departments: A systematic review Annals of Emergency Medicine, 58 (1),pp. 41-52. http://dx.doi.org/10.1016/j.annemergmed.2011.03.007

2. Anderson E.S., Hsieh D., Alter H.J. (2016) Social Emergency Medicine: Embracing the Dual Role of the Emergency Department in Acute Care and Population Health. Annals of Emergency Medicine, 68 (1) , pp. 21-25. http://dx.doi.org/10.1016/j.annemergmed.2016.01.005

3. Emergency Department Visits: https://www.cdc.gov/nchs/fastats/emergency-department.htm. Retrieved on 20 December 2017.

4. Hudon C, Sanche S, Haggerty JL (2016) Personal Characteristics and Experience of Primary Care Predicting Frequent Use of Emergency Department: A Prospective Cohort Study. PLOS ONE 11(6): e0157489. https://doi.org/10.1371/journal.pone.0157489

5. Johnson, Steven Ross (2017). Giving in to providing primary care in the ED. http://www.modernhealthcare.com/article/20170811/NEWS/170819966

6. Maeng DD, Hao J, Bulger JB. Patterns of Multiple Emergency Department Visits: Do Primary Care Physicians Matter? The Permanente Journal. 2017;21:16-063. doi:10.7812/TPP/16-063.

7. Moore B, Stocks C, Owens P. “Trends in Emergency Department Visits, 2006-2014” Healthcare Cost and Utilization Project. Sept 2017.