Emergency Department Utilization: Facts and Myths Lynne D. Richardson, M.D., F.A.C.E.P. Vice Chair and Associate Professor Department of Emergency Medicine Mount Sinai School of Medicine August 26, 2009

THE FACTS l Emergency Department Utilization –Who? –Why? l Emergency Department Crowding –What? –Why?

MYTH #1: “Increasing penetration of managed care will decrease the use of emergency departments.”

Annual U.S. ED Visits & EDs 1995 – 2006 (NHAMCS) 2006

The Emergency Department: A Unique Care Provider l Immediate care available 24 hours/day; 7 days/week l Complex life-saving interventions – simple first aid l access, regardless of ability to pay, mandated by federal law (EMTALA) l only available access to care for many vulnerable and disenfranchised individuals

The Emergency Department The Ultimate “Safety Net” Provider ED disproportionately used by: l patients without insurance l patients with Medicaid l patients without primary care physicians l members of racial and ethnic minorities l other “vulnerable populations”

MYTH #2 “Emergency departments are used mainly by patients who have nowhere else to go: uninsured, illegal immigrants, homeless, etc, etc.”

ED Visit Rates by Payment Source (NHAMCS 2006)

ED Visits by Payment Source (NHAMCS 2006)

U.S. Hospital Admissions by Route (NHAMCS 1996, 2006)

U.S. ED Visit Rates by patient age, race & ethnicity: 2005 (NHAMCS)

MYTH #3 “There is frequent misuse or inappropriate use of the ED for non-urgent problems”

ED Patient Acuity ( ED Patient Acuity (NHAMCS 2006)

EMPATH: Emergency Medicine Patients’ Access to Healthcare Principal Reasons for Coming to the ED l Medical Necessity l ED Preference l Convenience l Affordability l Limitations of Insurance Ragin et al, Acad Emerg Med 2005

EMPATH Study: Conclusions Use of the ED is driven by: l comprehensive scope of services l Immediate availability of services l quality of care provided l lack of affordable alternatives

Emergency Department CROWDING l Definitions & Measures l Causes of Crowding l Impact on patient outcomes l Short term strategies l Long term solutions

ED Crowding: Asplin’s Model

ED Crowding: “Upstream” (INPUT) Issues l Inadequate primary care capacity l Insufficient “walk in” & off hours availability of PCPs l Increasing number of uninsured l Declining Medicaid enrollment l Declining coverage for immigrants l Less funding for uncompensated care

ED Crowding: THROUGHPUT issues l Increasing acuity l Increasing volume l Staff shortages: particularly nurses l Operational inefficiencies: –Registration –Laboratory –Radiology –Consults

ED Crowding: OUTPUT Issues Boarding of admitted patients l Decreasing hospital bed capacity l Institutional / organizational culture l Declining reimbursement l Shrinking hospital profit margins Decreased primary care capacity Insufficient access to specialty care

ED Boarding of Admitted Patients l Often cited as #1 cause of ED Crowding* l 62.5% hospitals board admitted patients** –14.9% “board” on inpatient units –35.6% observation/clinical decision unit –35.2% electronic dashboard –21.1% full capacity protocol l 19.5 % expanded ED within past 2 years l 31.5% have ED expansion plans *GAO Report; ACEP Task Force; **NHAMCS 2007 E-Stat

Adverse Impact on Outcomes l Increased waiting times l Increases in leaving without treatment or AMA l Increased risk of in-hospital mortality l Increased time to antibiotics for pneumonia l Reduced promptness & quality of pain management

“ Knowing is not enough, we must apply. Willing is not enough, we must do.” Goethe

RWJF Urgent Matters Program l National program to develop solutions to ED Crowding l Elmhurst Hospital one of ten sites l Results released May/June 2004 summary available at

Institute of Medicine Report on Institute of Medicine Report on Future of Emergency Care in the United States l Key Findings & Recommendations –released June 2006 l Hospital-Based ED Care l Emergency Care for Children l Pre-hospital Emergency Care

IOM Future of Emergency Care Recommendations l Improve hospital efficiency & patient flow l A coordinated, regionalized, accountable EMS system l Increased reimbursement l Increased resources for research & disaster preparedness l Focused attention to care of children

Williams, R. NEJM, –ED: High fixed costs; low marginal costs –True costs of non-urgent care in the ED are relatively low Tyrance, P. AJPH, 1996 –Only 12% of “ED spending” by uninsured –ED expenditures only 1.9% of US health costs –Decreasing ED use will not generate much overall US health cost savings Cost of Care in the ED