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Primary Care and Emergency Department Decision Making
Jennifer E. McNulty, MD;
Louis C. Hampers, MD;
Steven E. Krug, MD
Arch Pediatr Adolesc Med. 2001;155:1266-1270.
ABSTRACT
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Objective To determine the effect of primary care status on decision making in
the pediatric emergency department (ED).
Setting Urban tertiary care children's hospital.
Design Examining physicians prospectively completed questionnaires describing
the presence of and their familiarity with patients' primary care providers
(PCPs), as well as several relevant clinical factors.
Patients We prospectively surveyed care for patients with triage temperature
of 38.5°C or higher or symptoms of gastroenteritis between August 1, 1999,
and February 15, 2000.
Outcome Measures Intravenous fluid use, hospital admission status, rates of diagnostic
testing and interventions, mean total costs, and length of ED stay.
Results Among 1166 nonreferred patients, no PCP was identified for 164 patients
and PCPs for 1002. The groups did not differ on ethnicity, mean age-adjusted
vital signs, triage category, initial appearance, patient care setting (main
ED or urgent care clinic), time of day, day of week, certainty of diagnosis,
or perceived importance of follow-up. Mean unadjusted direct hospital costs
for diagnostic testing were significantly higher for the group without PCPs,
$23 vs $16. In regression models controlling for age, ethnicity, insurance
status, patient care setting, ED attending physician, temperature, and initial
appearance, the absence of a PCP was associated with an increased likelihood
of diagnostic testing. Compared with a subset of the cohort with PCPs who
were familiar to the treating physicians, the group without PCPs also had
a significantly higher rate of intravenous fluid administration.
Conclusion In this patient population, ED physicians may vary their assessment
and management decisions based on primary care status.
INTRODUCTION
LACK OF a primary care provider (PCP) is a well established problem
in the United States.1 Numerous studies2, 3, 4, 5, 6, 7, 8, 9, 10, 11
have described the adverse effects of episodic and discontinuous care on the
health of underinsured children from low-income families. Although the magnitude
of the effect is unknown, it is often argued that inadequate access to a PCP
also increases health care costs by directing the care of low-acuity concerns
away from a low-cost office setting to a less efficient emergency department
(ED).12, 13, 14 Also
unknown are the ways in which the absence of a reliable provider of follow-up
care may affect medical decision making during an ED visit. Still, numerous
studies15, 16, 17, 18, 19, 20, 21, 22
have noted that physicians' decisions are based on many nonmedical factors.
It is conceivable that patients of comparable acuity are managed differently
if they have no PCP, further contributing to ultimate societal costs.
Identification of such an effect would have public policy implications.
In the absence of gatekeeping or triage mechanisms, attachment to a PCP may
decrease unnecessary ED resource use. Conversely, independent of traditional
measures of acuity, EDs caring for a large proportion of underserved children
could justifiably demand a higher level of reimbursement for such visits.
By prospectively analyzing the care of patients in our ED, we sought
to determine the effect of perceptions of reliable follow-up on physicians'
decision making. Our hypothesis was that the presence of and familiarity with
a PCP were associated with variations in ED assessment and management.
PATIENTS AND METHODS
This study took place in an urban, university-affiliated pediatric ED.
The annual patient volume approximated 40 000 visits. Patients presenting
to the ED were triaged and placed in either the main ED or the urgent care
clinic per usual protocol. A data collection sheet was attached to every medical
chart. During the study, August 1, 1999, through February 15, 2000, physicians
providing care in the ED and urgent care clinic were pediatric, family practice,
and emergency medicine residents and board-certified pediatricians. Attending
physicians and fellows also completed portions of the data collection forms
and supervised the resident physicians. All physicians were blinded to the
specific goals of the study.
Inclusion criteria were age younger than 18 years, absence of chronic
illness, and either triage temperature of 38.5°C or higher or symptoms
of gastroenteritis. Chronic illness was defined as the presence of a tracheostomy,
developmental delay, seizures, sickle cell anemia, cancer, a transplant, metabolic
disease, human immunodeficiency virus, or a ventriculoperitoneal shunt. Physicians
then provided data regarding the patient's clinical appearance, whether the
caregiver could identify a PCP for the patient, and the name of that PCP or
clinic site, if applicable. If a PCP was identified, the physicians (attendings
and residents) also recorded whether they considered this PCP or clinic "familiar"
to them; if so, they noted their opinion of the accessibility and quality
of that PCP. Definitions of each of these variables were based on each provider's
own interpretation of the variable (eg, "familiar" PCP). Physicians also indicated
whether the PCP had seen the patient in the last week or had telephoned in
a referral, and if contact with the PCP had changed the patient's ED workup
or management.
The primary investigator (J.E.M.) then reviewed the medical records
and further screened the charts for inclusion criteria. Several patients who
had chronic illnesses other than those defined in the previous paragraph were
excluded from the study. Information extracted from the medical records detailed
the patients' age, ethnicity, insurance status, vital signs, and triage category.
Details of the clinical course also extracted from the medical record included
diagnostic tests ordered, intravenous (IV) fluid and parenteral medication
administration, hospital admission and discharge times, final disposition,
and which attending and resident physicians saw the patient. Total diagnostic
test costs were calculated using a table of direct costs from the hospital's
laboratory and radiological cost centers.
The hospital's institutional review board reviewed and approved the
protocol.
Data were input using available software programs (Epi Info version
6.02; Centers for Disease Control and Prevention, Atlanta, Ga; and Microsoft
Excel 97; Microsoft Corp, Redmond, Wash). Data were then imported to a statistical
software program (SPSS version 10.0.5; SPSS Inc, Chicago, Ill) for analysis.
Continuous variables were analyzed using analysis of variance; when the variable
was not normally distributed, a Kruskal-Wallis test was performed (age and
cost).  2 Tests were used for initial analysis of categorical
data. Linear regression models were used in analyzing continuous variables,
incorporating patients' age, vital signs, initial appearance, ethnicity, language,
insurance status, patient care setting, and ED attending physician, to produce
adjusted means for patient costs and lengths of ED stay. For categorical variables
(any intervention, hospital admission status, and incidence of IV fluid or
medication administration), multinomial logistic regression models were constructed
using the same variables. In addition, both regression analyses used backward
elimination to construct parsimonious models.
RESULTS
During the study, 1284 data forms were completed for eligible patients.
One hundred eighteen patients had been directly referred to the ED by their
PCPs. These patients were excluded because their PCPs, in many cases, had
dictated specific components of a care plan, influencing medical decision
making. This left 1166 patient encounters appropriate for analysis. Nine hundred
seventy-two patients (83.4%) were seen in the main ED, and 194 patients (16.6%)
were seen in the urgent care clinic. A random surveillance of inappropriately
excluded patients was conducted approximately 1 day every 2 weeks during the
study; this yielded 60 medical charts. Daily inclusion rates for eligible
patients ranged from 60% to 90%. Physicians' failure to complete the forms
or failure of the clerical staff to place forms on the medical charts were
the main reasons for the failure to enroll potentially eligible subjects.
Data collected from the inappropriately excluded patients' medical records
revealed no differences between the included and missed patients in ethnicity,
insurance status, patient care setting, or vital signs. The missed group was
significantly younger than the included group; median ages were 21 vs 25 months
(P<.01).
The group without PCPs was compared with the group with PCPs. Demographic
and clinical data for the 2 cohorts are presented in Table 1. The patients without PCPs were less likely to speak English
(65.2% vs 84.5%, P<.01). They were also less likely
to be insured (18.9% vs 10.1%, P<.01). The cohort
without PCPs was slightly older (median age, 49 months) than the cohort with
PCPs (median age, 38 months). The 2 cohorts did not differ significantly regarding
ethnicity, sex, patient care setting (ED vs urgent care clinic), initial clinical
appearance, vital signs, certainty of diagnosis, or need for follow-up.
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Table 1. Demographic and Clinical Data*
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Subsequently, the cohorts were further analyzed in subgroups; 461 patients
(39.5%) had a PCP classified as "familiar" to the ED attending physician or
fellow and 541 patients (46.4%) had an "unfamiliar" PCP, with 164 patients
(14.1%) identifying no PCP.
Emergency department providers contacted 575 (57.4%) PCPs during the
patients' ED stays and indicated that direct input from the PCPs altered ED
diagnostic assessment or management in 1.2% of visits.
Within the cohort of patients with PCPs, ED providers indicated that
they had "good" or "excellent" confidence in the history provided by the family
in 82.0% of cases vs only 61.6% within the cohort without PCPs (P<.01). Furthermore, in 87.1% of patients with PCPs, the treating
physician had "good" or "excellent" confidence in the family's ability to
comply with the follow-up instructions, compared with only 72.0% of patients
without PCPs (P<.01).
Table 2 presents the unadjusted
analysis of ED management across the cohorts with and without PCPs. Incidence
of hospital admission, diagnostic testing, and mean test cost per patient
varied significantly; incidence of IV hydration and mean length of ED stay
did not differ. The length of ED stay for the cohort without PCPs ranged from
25 to 1280 minutes; the interquartile ranges were 75, 110, and 189 minutes.
The length of ED stay for the cohort with PCPs ranged from 25 to 1480 minutes;
the interquartile ranges were 70, 100, and 155 minutes.
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Table 2. Comparison of Emergency Department Management of Patients
Grouped by Primary Care Physician (PCP) Status*
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Table 3 details the adjusted
differences in ED assessment and management, comparing the 2 cohorts with
each other (with vs without PCPs) and the cohort without PCPs with the group
with familiar PCPs. Regression models incorporated patients' age, vital signs,
clinical appearance, ethnicity, language, insurance status, patient care setting,
and ED attending physician. The mean length of the ED visit was adjusted for
hospital admission status.
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Table 3. Adjusted Differences in Emergency Department (ED) Management
Based on Primary Care Physician (PCP) Status*
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Compared with the cohort with PCPs, the cohort without PCPs was more
likely to have had a diagnostic test performed in the ED (OR, 1.8; 95% CI,
1.2-2.8). Although there was a trend toward greater resource use in the cohort
without PCPs, differences in mean diagnostic test costs (mean difference,
28%; 95% CI, –11 to 68), likelihood of hospital admission (OR, 2.0;
95% CI, 0.8-5.4), and use of IV hydration (OR, 1.8; 95% CI, 0.9-4.0) did not
reach statistical significance. There was also a trend toward a longer mean
length of ED stay for the cohort without PCPs (mean difference, 10 minutes;
95% CI, –11 to 31).
When the groups with and without PCPs were compared in the same regression
models, the group without PCPs was significantly more likely to have received
IV fluids (OR, 4.9; 95% CI, 1.8-12.8) and undergone diagnostic testing (OR,
1.8; 95% CI, 1.1-2.9) than the group with familiar PCPs. The 2 groups did
not differ significantly regarding likelihood of hospital admission, mean
diagnostic test costs, or mean length of ED stay. Within the cohort with PCPs,
the patients with and without familiar PCPs were not significantly different
regarding IV fluid administration, diagnostic testing, hospital admission,
diagnostic test costs, or length of ED stay.
COMMENT
The interplay between PCPs and ED physicians is complex. Few would disagree
that the interests of patients are well served through a constructive collaboration
between these 2 groups. This collaboration begins with an understanding of
the role that each will play in the management of an acute illness. However,
when patients have no PCP, the ED physician must do without a valuable resource.
For the population studied, ED physicians may have varied their approach
based on the patient's primary care status. These variations remained after
controlling for numerous clinical and demographic factors, including acuity
and insurance status. Lack of access to a PCP, in itself, was a risk factor
for more extensive ED evaluations. Also, the ED physician's familiarity with
a PCP may influence diagnostic testing and interventions in the ED.
At first glance, it may seem intuitive that uncertainty regarding reliable
follow-up should prompt more diagnostic testing. However, before our study,
a reasonable counterhypothesis existed that the input of PCPs might encourage
additional resource use and, therefore, raise costs in treating patients with
PCPs, including those who were nonreferred. It was conceivable that the PCPs,
unable to acutely evaluate their patients, would urge the ED staff to manage
these patients more conservatively. Although there were anecdotal examples
of "unnecessary" diagnostic testing and administration of IV fluids or parenteral
antibiotics at the insistence of PCPs, contact with the PCP rarely changed
the ED course and had no effect on total costs.
The effects of primary care status on ED decision making have important
public policy implications. The role of managed care organizations as gatekeepers
to ED care is becoming increasingly unpopular. Nevertheless, it is argued
that substantial savings are realized by redirecting nonurgent complaints
to the office setting.22, 23 Our
findings do not dispute this claim. However, we suggest that some of the decreased
ED resource use evident in these models may be because of the identification
of a PCP for these patients.
Third-party payers, including government, have attempted to develop
measures of patient complexity and medical decision making. Our findings indicate
that primary care status should be considered in these analyses. Independent
of the other clinical and demographic factors, lack of a PCP complicated ED
decision making. Acknowledgment of this effect may assist urban EDs in seeking
adequate reimbursement for patient visits.
By confining our study to generally healthy children and adolescents
with a narrow range of complaints (ie, fever or symptoms of gastroenteritis),
we identified similar cohorts of patients. We recorded the patients' age,
vital signs, triage level, and general appearance to quantitate their severity
of illness and included these in our regression models. However, various clinical
or historical variables may have remained unmeasured.
Unfortunately, the missed group of inappropriately excluded patients
was significantly younger than the included group. Our surveillance on these
excluded patients was basic; collecting detailed data on every patient would
have been time-consuming without the certain gain of useful information. We
believe that our results might have been more significant had we captured
this group of younger patients, but this is only speculative. We think that
this group may have been at higher risk for the interventions described herein,
and inclusion of them would have strengthened our findings. Nevertheless,
because of the size of our study population, our data accurately represent
the medical decision making in our ED.
Although we recognize that ethnicity as a single independent variable
in our models is a crude and incomplete measure,24
it was important to include it because it represented information that was
readily available to ED decision makers. Our attempts to isolate the effects
of primary care status also prompted us to include insurance status as an
additional independent variable. However, primary care status likely covaried
with other important variables not directly measured, such as parental income
and educational levels, language and cultural barriers, single-parenting,
and lack of transportation.25 Our results do
not establish a direct, causative link between increased ED resource use and
the content of primary care; rather, the inability to identify a PCP may serve
as a marker for socially disadvantaged patients, for whom more extensive evaluation
is indicated.
We made no effort to independently verify a caregiver's report of the
patient's primary care status. Undoubtedly, some patients with a PCP were
misclassified into the group without PCPs (and vice versa). However, because
our outcomes of interest were measures of medical decision making, our main
independent variable was the ED physician's perception of the patient's primary
care status.
Future research can answer many questions regarding the way ED physicians
and PCPs practice as part of an integrated medical community. Focusing on
the evaluation and management of specific disease states or compiling larger
data sets may disclose more differences than those described herein. Yet,
our findings demonstrate the effect a PCP may have on ED management. This
previously unstudied effect on health care delivery has public health implications.
It highlights the cost savings associated with accessible primary care and
contains an important message for government agencies and other payers who
reimburse providers of urgent and emergency care to underserved populations.
AUTHOR INFORMATION
Accepted for publication May 20, 2001.
We thank the clerks, nurses, and physicians working in the emergency
department at Children's Memorial Hospital, Chicago, Ill, for their help in
completing surveys; Helen Binns for her help in preparation of the survey
and manuscript; and Salaeha Shariff for her help in data entry.
What This Study Adds
Lack of access to a PCP adversely affects the health of children. Primary
care providers may also reduce societal costs by directing nonurgent patients
away from the ED. However, it is unclear how attachment to a PCP affects medical
decision making in the ED.
Despite controlling for multiple clinical and demographic factors, children
and adolescents without a PCP had higher rates of ED resource use. This effect
was independent of gatekeeping and triage mechanisms. Conversely, a previously
undescribed additional cost to EDs caring for underserved populations has
now been documented.
From the Division of Pediatric Emergency Medicine, Department of Pediatrics,
Children's Memorial Hospital, Chicago, Ill (Drs McNulty and Krug); and the
Section of Pediatric Emergency Medicine, Department of Pediatrics, The Children's
Hospital, Denver, Colo (Dr Hampers).
Corresponding author: Jennifer E. McNulty, MD, Division of Pediatric
Emergency Medicine, Department of Pediatrics, Children's Memorial Hospital,
Campus Box 62, 2300 Children's Plaza, Chicago, IL 60614 (e-mail: jenemcnulty{at}yahoo.com).
REFERENCES
| |
1. Newacheck PW, Hughes DC, Stoddard JJ. Children's access to primary care: differences by race, income, and
insurance status. Pediatrics. 1996;97:26-32.
FREE FULL TEXT
2. Chessare JB. Utilization of emergency services among patients of a pediatric group
practice. Pediatr Emerg Care. 1986;2:227-230.
PUBMED
3. DeAngelis C, Fosarelli P, Duggan AK. Use of the emergency department by children enrolled in a primary care
clinic. Pediatr Emerg Care. 1985;1:61-65.
PUBMED
4. Halperin R, Meyers AR, Alpert JJ. Utilization of pediatric emergency services. Pediatr Clin North Am. 1979;26:747-757.
ISI
| PUBMED
5. Chande VT, Krug SE, Warm EF. Pediatric emergency department utilization habits: a consumer survey. Pediatr Emerg Care. 1996;12:27-30.
FULL TEXT
|
ISI
| PUBMED
6. St Peter RF, Newacheck PW, Halfon N. Access to care for poor children: separate and unequal? JAMA. 1992;267:2760-2764.
ABSTRACT
7. Lowe RA, Young GP, Reinke B, White JD, Auerbach PS. Indigent health care in emergency medicine: an academic perspective. Ann Emerg Med. 1991;20:790-794.
FULL TEXT
|
ISI
| PUBMED
8. Clancy CM, Eisenberg JM. Emergency medicine in population-based systems of care. Ann Emerg Med. 1997;30:800-803.
FULL TEXT
|
ISI
| PUBMED
9. Weitzman M, Moomaw MS, Messenger KP. An after-hours pediatric clinic for an entire urban community: utilization
and effectiveness of follow-up care. Pediatrics. 1980;65:964-970.
FREE FULL TEXT
10. Fosarelli P, DeAngelis C, Kaszuba A. Compliance with follow-up appointments generated in a pediatric emergency
room. Am J Prev Med. 1985;1:23-29.
PUBMED
11. Vivier PM, Lewander WJ, Block SH, Simon PR, Alario AJ, Linakis JG. Is continuity of care preserved in children who utilized the pediatric
emergency department? Pediatrics. 1995;95:37-41.
FREE FULL TEXT
12. Hurley RE, Freund DA, Taylor AM. Emergency room use and primary care case management: evidence from
four Medicaid demonstration programs. Am J Public Health. 1989;79:843-846.
FREE FULL TEXT
13. Piehl MD, Clemens CJ, Joines JD. Decreasing emergency department use by children enrolled in the Medicaid
program by improving access to primary care. Arch Pediatr Adolesc Med. 2000;154:791-795.
FREE FULL TEXT
14. Gadomski AM, Perkis V, Horton L, Cross S, Stanton B. Diverting managed care Medicaid patients from pediatric emergency department
use. Pediatrics. 1995;95:170-178.
FREE FULL TEXT
15. Hampers LC, Cha S, Gutglass D, Krug SE, Binns H. The effect of price information on test-ordering and patient outcomes
in a pediatric emergency department. Pediatrics. 1999;103:877-882.
FREE FULL TEXT
16. McLeod PJ, Tamblyn RM, Gayton D, et al. Use of standardized patients to assess between-physician variations
in resource utilization. JAMA. 1997;278:1164-1168.
ABSTRACT
17. Lawthers AG, Localio AR, Laird NM, Lipsitz S, Hebert L, Brennan TA. Physicians' perceptions of the risk of being sued. J Health Polit Policy Law. 1992;17:463-482.
18. Macario A, Roizen MF, Thisted RA, Kim S, Orkin FK, Phelps C. Reassessment of preoperative laboratory testing has changed the test-ordering
patterns of physicians. Surg Gynecol Obstet. 1992;175:539-547.
ISI
| PUBMED
19. Scholer SJ, Pituch K, Orr DP, Clark D, Dittus RS. Effect of health care system factors on test ordering. Arch Pediatr Adolesc Med. 1996;150:1154-1159.
ABSTRACT
20. McGillivray DL, Roberts-Brauer R, Kramer MS. Diagnostic test ordering in the evaluation of febrile children. AJDC. 1993;147:870-874.
21. Krug SE, Paul RI, Chessare JB, Christopher N, Satkowiak L. Hospital admissions of children from the emergency department: are
decisions regarding children on public assistance different? Pediatr Emerg Care. 1997;13:87-91.
FULL TEXT
|
ISI
| PUBMED
22. Starfield B, Powe NR, Weiner JR, et al. Costs vs quality in different types of primary care settings. JAMA. 1994;272:1903-1908.
ABSTRACT
23. Baker LC, Baker LS. Excess cost of emergency department visits for nonurgent care. Health Aff (Millwood). 1994;13:162-171.
ABSTRACT
24. Rivara FP, Finberg L. Use of the terms race and ethnicity [editorial]. Arch Pediatr Adolesc Med. 2001;155:119.
FREE FULL TEXT
25. Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Language barriers and resource utilization in a pediatric emergency
department. Pediatrics. 1999;103:1253-1256.
FREE FULL TEXT
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