Are we ignoring the systemic factors behind “inappropriate” use of emergency care?

November 11th, 2019

Emergency department visits for non-urgent issues are prevalent in the U.S., specifically among uninsured patients and patients with chronic health conditions. These so-called “inappropriate” or “avoidable” ED visits cost the health care system billions of dollars and may increase ED crowding and wait times.

Given the high cost of ED services and the availability of urgent care and other health care sites, policymakers have tried to encourage patients to use primary are and urgent care rather than the ED for non-urgent health problems. However, targeting patients in an effort to reduce “unnecessary” ED use may be misguided and harmful, write University of Pennsylvania doctors Krisda Chaiyachati and Shreya Kangovi, in a recent editorial in BMJ Safety and Quality. 

As Chaiyachati and Kangovi point out, labeling certain ED visits as “inappropriate” or “avoidable” attributes the problem to patient decisions, ignoring broader systemic factors that have a much greater impact on ED overuse. When we characterize ED visits as “inappropriate,” we are essentially faulting patients for making the decision to go to the ED; however there is a lot more behind that decision than simply a patient’s choice. 

“We may blame patients for visiting the ED inappropriately, when in reality, health care systems are often designed to funnel patients towards the ED,” Chaiyachati and Kangovi write. For example, health care services provided in the hospital generate far more revenue than those provided as an outpatient. While policymakers may be trying to reduce ED use to save money, hospitals may be doing the opposite, because it makes them more money.

In a particularly apt example, when Dr. Barbara McAneny launched a project to reduce unnecessary ED visits for cancer patients, nearby hospitals began sending flyers in the mail to patients to encourage them to go to the ED. The flyers read, “If the complications of your cancer seem urgent and you can’t reach your doctor, a trip to the emergency department could save your life.” Billboards advertising hospital ED wait times are another way hospitals encourage ED use, when going to a primary care clinic or urgent care would be cheaper. 

Even when hospitals do not directly encourage more ED use, patients may be referred to the ED by general practitioners because hospitals have certain resources that may not be available in primary care. As Chaiyachati and Kangovi write, “Primary care practices and community-based services have fewer resources to manage the growing complexity of aging, chronically ill and comorbid populations” while EDs are “convenient one-stop shops replete with resources.” It makes sense that patients would go to the ED if they or their clinician suspect an urgent problem. 

If we want to reduce ED use, we should not increase cost sharing for ED visits like Anthem Insurance tried to do, by denying payment for ED visits that turn out not to be emergencies. Instead, we should make primary care and community-based facilities more equipped to handle urgent complaints. This will require increasing “after hours” care, as many outpatient facilities have done, but also potentially growing the clinical capacity of outpatient facilities, so that when patients come to them with an urgent problem, they have the staff and technology to handle it. 

Chaiyachati and Kangovi point out that we should look further upstream to reduce ED use, by improving the community conditions in low-income areas. “If our goal is truly to reduce ED use, then it makes sense to invest in interventions that address the underlying socioeconomic issues—hunger, joblessness, trauma—that often drive acute illness and ED utilisation in the first place,” they write.