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A Night At the ER

Joe Cantlupe, for HealthLeaders Media, June 10, 2010

I remember the night our teen-age son complained about terrible stomach pains and then he said he had trouble breathing. It was on the weekend, the netherworld of medical care. Should we go to the nearby hospital emergency department? Should we wait, or leave a message on the family physician's answering service?

Not much debate. We went to the emergency department.

It's no secret that some people use the emergency room as a quick cure all, when they should be going to see their primary care doctor, me included. Such action balloons medical costs. But when your child feels sick, it's a different story and you don't have that immediate power of hindsight.

But questionable ailments don't stop with children. Sandra Schneider, MD, had a bad stomachache, too, around 2 a.m. on a Thursday night. But she decided to wait it out. She waited to see her primary care physician when the doctor could see her. That was 14 hours after she first felt pain. Looking back, she wonders if she should have just gone to the ER. And that's not only because she's president-elect of the American College of Emergency Physicians.

I talked to her about emergency care in the wake of a Excellus BlueCross BlueShield report that says in Upstate New York, two out of five non-overnight visits to hospital emergency departments are unnecessary. My colleague Cheryl Clark quoted criticism of the report by Gerard Brogan, MD, president of the New York American College of Emergency Physicians, as well as Schneider. They said the report lacked data and was inconclusive and unfair.

The Excellus report, issued May 25, focuses on 640,000 trips to emergency rooms that patients made for such ailments like sore throats, ear aches, upper respiratory infections, and other minor medical problems in 2008, saying that many of these patients could just as easily have gone to a primary care doctor for treatment, at much lower cost.

The report said that one of four ER visits in which the patient was treated and released in the same day turned out to be for a medical issue in which care wasn't needed in a 12-hour period. Some treatments, such as ear infections, should have been treated sooner, but easily could have been done in a primary care setting, the report states.

The report itself displays a big hole, simply by its language. It says the analysis covers the "number of potentially unnecessary hospital room visits" that it says led to overcrowding and wasteful spending.

Potentially? That leaves too much room for, er, potential variables. Schneider agreed that the term was ambiguous. "It says potentially–potentially something your primary care physician could handle? But it could be potentially something your primary care physician couldn't handle, and if you didn't come to the emergency department, you could have lost valuable time," she says. "The report doesn't look at what the patient could have had."

In my conversation with them, officials of American College of Emergency Physicians were quick to summon other studies that they said contradict the Excellus findings, at least on a national level, about the usage of emergency departments. For instance, the The CDC's National Center for Health Statistics noted last month in a report, Emergency Department Visitors and Visits: Who Use Emergency Rooms in 2007, that 10% of emergency department, or ER visits by persons under age 65 were considered non-urgent, far less than the 25% figure in the Upstate New York study.

Schneider says primary care physicians are referring patients to the emergency department, and have been doing so for some time. In 1993 a study performed at Schneider's hospital, Strong Memorial Hospital in Rochester, showed that 88% of patients had a primary care physician and that 50% of them "had called their physician before coming to the emergency department and were told to come to the emergency department," she says. "This was an unpublished study involving 2,000 patients coming into our hospital. . . . We are in the process of repeating that study in our institution. To date, it appears that 80% of the patients have primary care physicians and that about 40% of them have been told to come to the emergency department.

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