According to the CDC’s National Center for Health Statistics “National Health Care Survey.” annual of emergency department visits jumped from 90.3 million in 1996 to more than 119 million in 2006, a 32 percent increase. At the same time, the percentage of non-obstetric hospital admissions that came through emergency departments climbed from 36 percent in 1996 to 50 percent in 2006.

“This means that a lot of diagnostic work is being done in the ER, and it is prolonging ER stays,” said Stephen Pitts, M.D., M.P.H., a fellow at the National Center for Health Statistics and an associate professor of emergency medicine at Emory University, who led the study.

The study strongly suggests that the growing use of emergency departments is directly related to the shortage of primary care physicians. Without a regular and continual source of care, patients are more likely to turn to emergency departments for treatment, said Pitts in an interview with AAFP News Now.

The study also reached the following conclusions.

·         Patients with Medicaid use the emergency department more frequently than patients with private insurance — 82 per 100 persons for Medicaid compared with 21 per 100 for private insurance. Medicaid patients have a harder time finding physicians who will treat them than do patients with private insurance, which accounts for the disparities in ER visits, Pitts said.

·         The average waiting time to see a physician in the emergency department was 56 minutes.

·         The rate of visits per 100 persons was about 36 percent for whites compared with nearly 80 percent for blacks, a fact that Pitts attributed to many blacks’ lower socioeconomic status and, consequently, their decreased access to physicians outside of ERs. Cultural factors also could play a role in discouraging blacks from seeking care from places other than ERs, Pitts said.

·         The rate of visits per 100 persons for Hispanics was about 35 percent, lower than the rate for whites. Pitts said this statistic could be a result of language and cultural barriers that make Hispanics less likely to report their visits to ERs.

·         Most ER visits occurred after normal business hours — 8 a.m. to 5 p.m. on weekdays — when 63 percent of adults and 73 percent of children younger than 15 came in.

Need to learn how to use ER facilities smarter.

Blogger Kevin Pho, MD, notes in a recent post:

One-fifth of patients coming to the ED did not have conditions requiring emergency care, and another one-fifth had urgent conditions that could have been treated in a primary care setting, the report shows.

The last point has resonance. The key is primary care and specialist access. When I work in ED fast-track, there is a good proportion who come in for medication refills and the like – simply because they can’t contact nor see their primary care physician.

Uninsured and Medicaid patients in some communities might have to wait six months or more for an appointment with a specialist. But if they go to an ED, they get all their needs met in one place at any time.

“The convenience of the emergency department really offsets the long waits that are associated with it” . . .

When patients use the ER, they get immediate attention to their ailments, but then return home with no means for follow up visits … no prevention until they return again to the ER for their next episode.

The uninsured actually are underrepresented in ER units compared to the overall population—17 percent of people in our country are uninsured, but they account for somewhere between ten and 15 percent of visits to the ER. When they do come in, they tend to put it off until the last possible moment, until they’re really sick.

If today’s uninsured were insured by a government/commercial system, they could then go to a primary care physician at a cost far lower than at hospital ER units. The case management plan for addressing their healthcare problem would be planned out by the primary care physician and the individual would stay healthier. This would also decrease the number of readmissions because follow-up care is provided outside the hospital.

Just one problem: there are not enough primary care physicians and they are not always located in the right place where those currently uninsured live.

The fact that there are fewer primary care doctors mean it’s hard to get appointments. If you call your doctor’s office and you say, “I’m really sick and coughing up green stuff,” and the doctor’s office says, “we can see you in two weeks,” you might think you need to go to the ER instead. But the issue you are running into is the queue to get in an see the relatively few primary care doctors is growing – at times beyond their ability to respond in a timely manner.

Considerable research indicates that a majority of policy makers and even doctors believe primary care doctors need to be paid more – to attract more medical students to pursue internal medicine instead of the more lucrative specialties.

While addressing primary care physician compensation, policy should also be focused on how to motivate more doctors to provide care in areas not now covered – rural and urban localities, in particular.

And there are other problems that backup into the ER. There’s a shortage of nurses and in-patient beds so you might get triage in the ER and have no room in the hospital for continued treatment.

There are no easy solutions. The ER can work on throughput issues. But that’s a tiny fraction of the problem. Hospitals cannot predict how many people show up in the ER. They cannot control how soon someone can get a bed if the hospital is short on beds or nurses. You can’t blame any one part of the system. You can’t say this is the ER’s fault, or the inpatient service department’s fault, or primary care physician’s fault. If we keep pointing fingers and blaming people, we’re not going to change anything. This is a system wide problem. If we are truly in the midst of coming healthcare reform, then all parties need to tackle this as a systemic issue … if healthcare reform is just about increasing access for the uninsured and decreasing the cost of the healthcare system, then we will have missed a huge opportunity to take a holistic approach to clinical care.




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