Underestimation of Disease Severity by Emergency Department Patients : Implications for Managed Care Jeffrey M. Caterino, M.D. C. James Holliman, M.D., F.A.C.E.P. Penn State University College of Medicine M. S. Hershey Medical Center Hershey, Pennsylvania, U.S.A.

Study Background ƒE.D.'s often criticized for having high % of "inappropriate" visits ƒCurrent attempts by managed care to screen patients' symptoms via phone prior to approving E.D. visit –Is this practice safe ?

Study Background : Findings from Prior Studies ƒ1980 ACEP study : –12 % of patients rated urgency of their condition lower than did the doctor –25 % of patients rated by doctor as needing urgent care thought they could wait –4 % judged by doctor to be more urgent in retrospect –Concluded : " Inappropriate utilization of E.D.'s appears to be more a perceptual issue than a real one"

Study Background : Other Prior Studies ƒ1985 study : only 10 % inappropriate visits ƒAll earlier studies were retrospective & had "non- emergent" visits mostly around 40 % (6 to 81 %) ƒElderly have low rates of "inappropriate" visits ƒ1996 followup study (to the 1980 ACEP study) showed same % severity assessments by patients & doctors as in 1980 study ƒ1996 Pittsburgh study : 6 % of Medicaid patients denied E.D. approval proved emergent

Current Study Objectives ƒDetermine differences in symptom severity assessment by E.D. patients and by emergency physicians (E.P.'s) ƒCorrelate these assessments with case management and disposition

Study Setting ƒM. S. Hershey Medical Center E.D. ƒUniversity Hospital ƒRural, suburban setting ƒAnnual census 28,000 ƒ20 % pediatric cases ƒLevel 1 trauma center ƒStaffed by faculty E.P.'s & residents

Study Design and Participants ƒProspective convenience sample of E.D. patients ƒIncluded : –All E.D. patients registered when first author in E.D. –Both day & night shifts –May to August 1996 ƒExcluded : –Patients treated by major trauma response team –Patients with psychiatric chief complaint

Study Methods ƒAll patients interviewed by first author & asked to class their Sx as emergent, urgent, or nonurgent ƒE.P. attending asked to class patients' Sx after initial exam, and again after workup was complete

Study Methods : Definitions of Acuity ƒEmergent –Care needed in < 1 hour ƒUrgent –Care needed within 6 hours ƒNonurgent –Care could safely wait > 24 hours

Study Results ƒTotal cases : 301 ƒMale / female : 151 / 150 ƒAge < 12 : 13 % ƒAge > 65 : 16 % ƒReferred to E.D. by health care professional : 37 %

Study Results Patient's Self - Classification % Emergent Urgent Non- urgent % Admitted Emergent Urgent Non- urgent E.P.'s post - workup classification (%) (of the 3 groups in column 1)

Study Results The "Non-urgent" Patient Self-Classed Group (n = 83) ƒ43 male, 40 female ƒ7 % age 65 ƒ40 % referred by health care professional ƒE.P.'s initial class : E.P.'s final class : –Emergent : 2 3 –Urgent : –Non-urgent : ƒAdmitted : 4 (5 %) ƒClass upgraded : 4 (5 %)

Comparison of Results to Prior Studies ƒ% "non-urgent" self-assessed by patients was higher (27 vs. 13 %) ƒSimilar % (35 vs. 33) of patients assessed by E.P. as needing emergent or urgent care in the non-urgent self-assessed group ƒRetrospective (post-workup) E.P. assessments down-class (17 %) more than up-class (5 %) case severity

Study Limitations ƒRelatively small number of patients ƒOne hospital & geographic area ƒ3 scale rather than 5 scale severity used ƒCase denominator altered by exclusion of major trauma & psychiatric patients

Study Conclusions ƒ5 % of study patients self-rated as non-urgent required hospital admission ƒ35 % of patients self-rated as nonurgent were rated higher severity by E.P. ƒAnother 5 % of patients rated by E.P. had severity upgraded after workup ƒPatient severity self-classification allows prediction of chance of admission ( Emergent : 46 %, Urgent : 27 %, Nonurgent : 5 %)

Relevance of Study to Managed Care ƒA significant % of patients with self-assessed minor symptoms may have serious illness and require urgent care ƒScreening of these patients by phone to deny E.D. visit approval is unsafe (for at least 5 %) ƒEven after screening exam, 5 % of cases are upgraded in severity by the E.P. ƒEven prospective severity assessment does NOT identify "unnecessary" E.D. visits

Further Studies Needed ƒLarger numbers of patients in different E.D.'s in different geographic areas ƒShould record case assessment both prospectively (pre-workup) and retrospectively (post-workup) ƒNeed to track carefully emergent treatments and post-admission care