One in five patients who went to the ED but were not sick enough to require an inpatient bed said they sought the emergency department because their primary care doctor told them to go there, according to a federal survey.
The Centers for Disease Control and Prevention's National Center for Health Statistics queried a large sample of non-admitted patients between the ages of 18 and 64 between January and June, 2011. The intent was to determine why they went to the ER instead of another less intense or less expensive care setting.
The issue has been a political flashpoint with emergency department doctors in recent years because of statements from members of the Obama Administration and other political figures implying that ED overcrowding might be largely remediated if there were simply more primary care doctors willing to see a wide spectrum of patients.
"People don't realize that a lot of the patients who get sent to our emergency centers are referred there by their physicians," said Andrew Sama, MD, president-elect of the American College of Emergency Physicians.
"Either they see the patient, and say, this is beyond what I can do in my private office, with limited resources, or they talk to the patient on the phone and say I'm concerned about your symptoms," Sama said.
"Or they know the patient has complex problems with subtle symptoms that can mean grievous issues, and they send them to us because we can do the diagnostic testing rapidly, or call on a colleague or specialist to get more detail."
It's true that many physicians across the country are not willing to see Medicaid patients or those with no insurance. Additionally, some physicians' schedules require appointments booked months in advance, as they intersperse office visit care with time on call or performing procedures.
Simply having more physicians in primary care settings willing to see patients in all income brackets and levels of insurance will help, Sama says, but it won't solve the problem.
Sama is the senior vice president for emergency services at North Shore Long Island Jewish Health System.
New policy proposals and practices sought by the administration or enabled by the Affordable Care Act will also modify demand, Sama says. For example, a proposal to pay primary care physicians who treat Medicaid patients at the same rate they treat Medicare patients, is now under review.
Other trends that may help the situation include an increasing number of retail and urgent care clinics.
But those developments are offset by the number of emergency departments around the country that have closed or are closing. The fact that those retail clinics operate in large part 9 to 5 and not on weekends, and that people without insurance may find the costs beyond their reach, Sama says.
"Even with the enhanced resources, these numbers are not going to go down," Sama said. He anticipates a continued 2% to 3% increase in emergency department utilization each year, which was estimated at 135 million annual visits in 2009.
The CDC survey also found that nearly four in five ED patients said they went to the ED because they had nowhere else to go. And two in three said they perceived their problem was so serious as to require immediate medical attention, according to a federal survey that's the first of its kind.
The results were sorted by health insurance status, area of residence, race, other indicators of health status and prior use of emergency care in the last year.
In a statement, the ACEP president David Seaberg, MD, said the report validates what ACEP's own surveys have long known.
"This confirms the results of a recent ACEP poll in which 85% of Americans with regular healthcare providers who visited the ED said they could not have waited to see their regular providers. The CDC report draws similar conclusions, even though it excludes the nearly 27% of emergency patients admitted to the hospital who are, by definition, the sickest patients.
"It also excludes seniors who tend to have more complicated health problems and are more likely to be admitted to the hospital from the ED."
The statement added "No matter how we slice and dice the data, the results always say the same thing: people come to the ED because they feel they need to be there. No patient should be self-diagnosing his or her medical condition. They cannot distinguish between discomfort that is a minor problem and discomfort that could be a killer. That is the emergency physician's job."
A CDC report on ED usage in May of 2010 prompted the organization to angrily ask for a more detailed report.
"It is critical to know, for example, how many patients use the ED, how many are admitted to the hospital from the ED, and the top reasons that people seek emergency care," Angela Gardner, MD, ACEP's then president, said at the time.
Among other findings from the current survey, 42.5% of these patients who were not seriously sick enough to be admitted said they believed their problem was too serious for a doctor's office and 54.5% said that only a hospital could help. About 9% arrived by ambulance.
Of those who said they lacked access to any other provider, 48% said their doctor's office was not open, 45.8% said the emergency department was the closest provider. About 17.7% said that most of their care is delivered in an emergency department.
The CDC survey also found that:
- Adults with public health plan coverage were twice as likely as those with no health insurance to visit the emergency department because their doctor's office was not open.
- Uninsured adults were more likely than those with private health insurance or a public health plan to visit the emergency department due to having no other place to go.
- Adults with unmet medical need were less likely than adults without unmet need to visit the emergency department because their doctor's office was not open and more likely to visit because they had no other place to go.