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To what extent are emergency departments being used for primary care?

Elsevier Health Sciences

There is some belief that Emergency Departments are being used for non-emergency medical care. In particular, do Medicaid recipients and uninsured patients overutilize ED for services better provided in other settings" In two studies conducted at Oregon Health and Science University, to be presented at the 2007 Society for Academic Emergency Medicine (SAEM) Annual Meeting, researchers have investigated some common assumptions about ED use and found some surprising results.

To analyze ED usage, a research tool called the "Emergency Department Algorithm" (EDA) has been developed that attempts to categorize all ED visits into four categories: non-emergency; emergency, primary care treatable; emergency, needing ED, but potentially avoidable; and emergency, needing ED, not avoidable. This algorithm was not designed to triage patients away from an ED or to deny payment or "punish patients." Rather, it was designed to help understand access to care, because patients with worse access to care outside the ED may be more likely to use EDs for conditions in the first three categories. Research conducted by Robert A. Lowe, MD, MPH, and Rochelle Fu, PhD, at the Center for Policy and Research in Emergency Medicine at Oregon Health & Science University concluded that this methodology - although promising - needs further refinement before it can be validated.

Many discussions of ED usage have centered on inappropriate or non-urgent use, use by Medicaid enrollees, and the generation of large and unnecessary costs. According to Dr. Lowe, "None of this is true. The concept of 'inappropriate' visits is naïve. Problems with determining which visits are appropriate have led to estimates from 11% to 82%. This illustrates the pitfalls of attempting to identify 'inappropriate' ED use for triage or reimbursement purposes."

In a related presentation, Daniel A. Handel, MD, MPH, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, studied the use of the ED by Medicaid patients and the perception that such patients are using the ED for primary care. With estimates ranging from 10-20% of Medicaid spending going to the ED, the study actually showed only 6.8% of Medicaid dollars were for ED-provided care. While 80% of Medicaid patients had no ED usage at all, fully 50% of all spending came from 3% of the patients. Dr. Handel suggests, "Medicaid spending for emergency department use is much less than previously thought. Legislative efforts to reduce this would have only a minimal impact on overall Medicaid expenditures."

The presentation about the EDA algorithm is entitled "Can 'Non-Emergency' Emergency Department Visits Shed Light on Access to Care"" by Robert Lowe MD, MPH. This paper will be presented at the 2007 SAEM Annual Meeting, May 16-19, 2007, Chicago, IL on Wednesday, May 16th, in the Plenary Session beginning at 1:00 PM in Sheraton 4 & 5 of the Sheraton Chicago Hotel & Towers. The paper discussing Medicaid spending is "What is the Cost of Emergency Department Utilization by Medicaid Enrollees"" by Daniel A. Handel, MD, MPH, John McConnell, PhD, Neal Wallace, PhD, and Charles Gallia, PhD. It will be presented on Friday, May 18th, in the Health Care Policy session beginning at 1:30 PM in room Michigan B.

Abstracts of the papers presented are published in Volume 14, Issue 5S, the May 2007 supplement of the official journal of the SAEM, Academic Emergency Medicine.

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