To ED or not to ED?: the Management and Measurement of Unscheduled Acute Care in the United States
October 30, 2014
In today’s healthcare system, patients have a plethora of options in seeking healthcare. Is the condition best treated at an urgent care center, retail clinic, hospital emergency department (ED), primary care or specialist facility, or a telehealth provider?
By Aditi Gupta, CAS, W’14
While patients have many options, little research or data infrastructure exists to help inform consumers seeking care to make informed decisions about where to find the acute care resources that they need. A patient experiencing difficulty speaking and altered mental status may be best treated at an ED, while a patient experiencing a sprain may be best treated at a primary care provider. Many emergency department visits are perceived to be non-urgent and recent data places the corresponding estimate at less than 10% (Pitts et al. 2010). The reality is that the majority of emergency department visits are for urgent conditions. Other factors related to the use of EDs including day of the week and time of day the care is needed, and access to facilities and providers available to treat the condition. In many cases, patients are left to decide for themselves without adequate information about where their best option of seeking care exists (Pitts et al. 2010).
Access to emergency care is dependent on location since patients must be quickly connected to the closest care facilities. Patients can thus be stratified geographically based on local hospitals and emergency departments (EDs). Patient utilization of emergency services can be analyzed using geographic information systems. For example, all individuals with a specific disease who visit a particular ED can be monitored to understand ED catchments. Such healthcare geographies provide hospitals and EDs with valuable information regarding local patterns of patient flow for emergency care. The units readily used to understand geographic variations in hospital use are the Dartmouth-defined Hospital Referral Regions (HRRs) and Hospital Service Areas (HSAs). HSAs and HRRs were developed using Medicare data from the early 1990s (Zhang et al. 2012) HSAs are based on the set of ZIP codes assigned to a location and include the hospitals located in that location. HRR units were then created from HSAs using neurosurgical and cardiovascular surgery referral patterns. While these geographic units provide useful insights, they are not relevant or specific enough to enable emergency care system planning and evaluation (Zhang et al. 2012). Another possible method of geographically defining units of emergency care is to group hospitals based on their shared responsibility for overlapping catchments. These groups are referred to as coalitions and may be composed of hospitals that do not have any existing relationships.
Unlike scheduled care, unplanned critical illness, such as trauma, stroke or cardiac arrest, can affect any individual and relies on the local emergency care system to deliver time-sensitive, life-saving care. In order to design and assess emergency care systems that are able to manage unplanned critical illness for a region, a population-based approach must be applied (Schuur and Venkatesh 2012). In this case, population health refers to the health of all people living in a geographic area and can be more aptly described as total population health. To support a population-based perspective, empiric identification of the geographies that EDs serve must be conducted to facilitate the development of a novel geographic unit of analysis that can better map population flow and match patient needs. The new geographic unit would demand cooperation as it would be composed of coalitions that share mutual responsibility for the regional population. Financial incentives coupled with innovative policy tools must be implemented to promote the exchange of resources and information among coalitions to bolster the emergency care capabilities of their regions. Population health can even be applied to develop novel forms of healthcare delivery, such as geographic ACOs that would be responsible for providing emergency care for a region.
One in five Americans make at least one visit to the ED each year. Over the past decade, the increase in ED utilization has outpaced growth of the general population, despite a national decline in the total number of ED facilities. One may ask why patients are utilizing the ED at increased rates. Data from the 2011 National Health Interview Survey suggests that 79.7% of adult patients chose to go to the emergency room due to “lack of access to other providers,” whereas 66% made their decision based upon their perceived seriousness of the medical problem (Gindi, 2012). However, patient decisions are not the only source of increased ED use. Among patients presenting to the ED for a problem other than an injury who called a health care professional, 80% were referred to the ED (Gindi, 2012).
Despite misconceptions, most patients who visit an ED for a non-emergent health problem do so because their health care provider sends them there. The provider either believed that he or she lacked a viable alternative or that the patient had a serious condition. Recently, substantial effort has been focused on controlling the costs of healthcare including the development of novel payment models that reward health delivery systems that can deliver high quality care at low costs (Morganti, 2013). A part of this dialogue has focused on decreasing emergency department utilization given the higher costs of treatment in the emergency department for unscheduled primary care treatable conditions.
While decreasing ED utilization may provide cost saving benefits, it may not translate into improved health outcomes without additional infrastructure support. Emergency department utilization is a direct reflection of community health status and the underlying system of care that is in place to support the health of the population (Schuur and Venkatesh 2012). That is, patients tend to utilize the ED due to a lack of adequate alternative community health resources. Community health resources can include many services, including public sources of information to foster informed decisions, primary and preventative health care, dental care, and treatment options for mental health and substance abuse conditions (Morganti, 2013).
The Emergency Care Coordination Center (ECCC), located within the Office of the Assistant Secretary for Preparedness and Response (ASPR), within the US Department of Health and Human Services (HSS), seeks to integrate acute care delivery into the broader healthcare system. ECCC was created to respond to the pressing needs of the nation’s emergency medical care system and promote coordination between all providers of care to ensure a system that is patient- and community- centered (“Emergency Care Coordination Center”). Without a model in place, patients and providers are unable to make informed decisions regarding their unscheduled acute care options. This can be achieved, in part, by collaborating with various stakeholders to identify opportunities, barriers, and goals to support the development of a conceptual model to manage acute unscheduled care. Provider perspectives, such as emergency physicians, urgent care centers, retail clinics and virtual/telehealth providers, should be sought out as well as those of patients, payers and hospital and health system administrators. Through further conversations with key opinion leaders and policy experts, concrete policy recommendations can be created to facilitate the transformation of the current fragmented system to deliver acute unscheduled care into one that meets all stakeholder needs while delivering high value care.
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