Posts Tagged health policy

Does a Visit to the ER Represent a Failure of the Health Care System?

Does this look like the failure of a health care system?

In a widely read article in the January 2011 issue of The New Yorker by Atul Gawande that details the efforts of Dr. Jeffrey Brennerto improve care to a number of high-cost patients in Camden, NJ; Dr. Brenner was quoted as saying “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise.” This observation has often been quoted by any number of health care policy wonks, health plan advocates, and politicians in efforts to justify their particular distaste for ‘unnecessary’ ER care. Like many such generalizations, Dr. Brenner’s comments are often taken out of context or misinterpreted, and in some cases have been used to denigrate the care provided in ERs, or the patients that rely on the ER. Dr. Brenner was referring to “failures of prevention and of timely, effective care” in the rest of the health care system, and I cannot disagree with him that ERs are often called upon to address these failures. Nonetheless, my antipathy for Dr. Brenner’s observation is that it is glib, and too easy to misconstrue.

Emergency Departments provide such a broad scope of services, and play so many roles in health care, that it is rather short-sighted to view ER visits as the if they were almost inevitably the result of misuse, abuse, inattention, inappropriate delay, or a failure of prevention. If someone falls off a ladder and breaks their leg, that obviously is not a failure of the health care system, unless of course you plan to hold the health care system responsible for poor ladder design. Likewise, not all heart attacks or strokes can be prevented by good primary care, Lipitor, aspirin, and exercise; and not all pneumonias represent a failure to immunize or prescribe controller inhalers for asthma. The reasons why the number of ER visits have grown so rapidly go way beyond the fact that the health care system often fails us; or that the ER is open 24/7; or the EMTALA mandate to treat everyone regardless of insurance status or ability to pay.

ERs have become the diagnostic centers of the health care system; and many patients are sent to the ER by their doctor specifically because of the broad array of diagnostic services available, ER physician expertise as ‘diagnosticologists’, the ready availability of specialist expertise, and the efficiency of ER workups. It would not surprise me if more than a third of all cancers in the chest and abdomen are first detected in the course of an ER visit. In addition, the ER fills many roles that, if they had to be met by other health care providers and venues, would render those providers or venues overwhelmed, even more inefficient, and often just unavailable. Imagine if primary care doctors, or even urgent care centers, had to repair all lacerations, or treat all kidney stones, or manage every alcoholic who drank himself into a stupor. Think what it would cost if those offices and facilities had to stay open until 2 am to accommodate those who were not able to get their care during office hours. You don’t have to imagine closing every ER in the country to realize that ER care is not just some regrettable but necessary safety net established to manage the failures of the health care system. Just watch what happens when the last ER in a community closes: you will find that ERs represent what is often the best of what the health care system offers: timeliness, efficiency, effectiveness, scope, availability, responsiveness, surge capacity, compassion, and decisiveness; and this will be sorely missed by the residents of that community.

The tendency of many to misconstrue comments like those of Dr. Brenner is reflected in a host of similar aspersions cast on the ER.  Jane Stevens also wrote an article about Dr. Brenner, and about a similar effort to reduce costs through an ER diversion program in Bend, Oregon, designed to help patients who frequently landed on the doorstep of the ER to get access to other, more appropriate places to get the things they needed, some health care related, but often focused on social service needs. The title of this article was “Improve health, lower health care costs by reducing emergency room visits”, implying that simply by blocking the door to our ERs, we could solve what is wrong with health care.  At least, this is how many readers were likely to interpret the message. Taken to an extreme, this is the kind of message that leads policy makers and legislators to believe that if they just stopped paying for ER visits, they could keep everyone healthy AND solve their budget crises.

Dr. Brenner’s linkage of ER visits to failure has also become insinuated into even the most thoughtful discussions about health care reform. Brad Wright wrote a post in the Kevin MD blog that pointed out the mistaken belief by many that universal health insurance would lead to a reduction in ER use. He noted that “people go to the emergency room for a host of reasons that have nothing to do with their insurance status. Among these reasons are low health literacy, a health care system that is often complicated to navigate and inaccessible for people who can’t get off work during typical business hours, and a lack of continuity of care that arises for a host of reasons. Waiting to be seen in the ER is no picnic, but for many people it is a more easily understood process than trying to get a referral to a specialist from their primary care physician–assuming they even have one.” As I have noted above, this accounts for just a fraction of the reasons why patients use the ER. Mr. Wright notes that consequently, reduced ER use should NOT be considered a measure of the success of health reform.

I believe that ER use is an indicator of many things, some reflecting the failures of our health care system and our social safety net; others reflecting great advances in acute care, resuscitation, and diagnostic services; and still others reflecting our society’s need for, and desire for, efficiency, availability, and timeliness of care. You can’t hope to cover all of these attributes in a single, facile observation, no matter how well intended.

This post also appears in The Fickle Finger.

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It’s All Excessive Medical Care In Hindsight

An 18th Century Diviner, courtesy Wikimedia Commons

An 18th Century Diviner, courtesy Wikimedia Commons

Buckle your seatbelts, kids, it’s going to be a bumpy ride.

In yet another installment of “emergency physicians don’t know what they’re doing,” KevinMD provides a guest post by gastroenterologist Michael Kirsch, entitled Does the bulk of excessive medical care happen in the ER? At its best, the piece is uninformed; at its worst, it’s insulting and unprofessional.

So let me answer you here, Dr. Kirsch: No, it doesn’t.

Read this beauty from the author (I guarantee he has not practiced in an emergency department (yes, department) since residency):

These unneeded medical tests and treatments are black and white, not gray. It occurs every day in every doctor’s office, including mine. The most dramatic example of it, however, is the care rendered in our emergency rooms. The volume and expense of care given there routinely is absolutely astonishing. It is wasting a fortune of money and exposing patients to the risks and anxieties of extensive testing, even for minor medical conditions. Whenever one of my patients sees me in the office to review a recent ER visit, I try to disguise my amazement, as I look through all the lab results, x-ray reports, CAT scan interpretations and EKG tracings – often performed for some innocent complaint that has already resolved on its own.

The clencher, of course, is my bolded text for emphasis. Remove the retrospectoscope, Dr. Kirsch. It’s daylight out! If you’ve figured out how to divine “minor medical conditions” and “innocent complaints” from badness, boy, you should be writing our textbooks, because we dumb emergency physicians can’t!

Yes, the epigastric pain is just innocent GERD after it gets better and the patient doesn’t deteriorate (hint: sometimes it’s an appy, like I diagnosed just last week!). Unfortunately, according to a Lancet study, 7% of patients with ischemic chest pain actually felt better after a GI cocktail. I’ve seen patients with tender abdomens with no other complaints who have STEMIs. I’ve also seen sharp, right-sided tender chest wall pain with an NSTEMI. We all have.

In the Emergency Department, I lack the benefit of knowing my patients. I often do not have the luxury of knowing their medical problems or medications, as they themselves often do not know them; I often have patients who cannot provide history to me; I often have patients who only have non-specific complaints: “weakness.”

I probably do order more tests than your average internist, but two points: don’t you think there’s a referral bias toward emergencies in a patient presenting to the emergency department? And two, how much of adult medicine is a waste? The vast majority of antibiotics for upper respiratory infections are prescribed by primary care physicians, not emergency ones. And we could certainly find an easy whipping boy in the PSA, which is ordered routinely across the country, yet where’s the data behind it? Apparently there’s no risks or anxieties to ordering cancer screening tests (many of which have a ton of false positives).

ER physicians should practice the same style of medicine that we all were taught to do during our medical training. Take a thorough history, perform an examination and then make appropriate recommendations. As a gastroenterologist, I see patients with chest burning in my office several times a week. The medical history allows me to determine if the chest discomfort is innocent or suspicious.

So you’re a gastroenterologist and you see chest burning. So, yeah, with your gigantic referral bias, most of your patients with chest burning probably do have GERD. I take all comers: the rich, the poor, those with a great primary care doctor and those who haven’t said a word to a physician in 20 years. And it’s now up to me to determine if this chest burning is of a concerning nature. (And by the way, the more we’re (we being emergency physicians) learning about acute coronary syndrome, the more we’re recognizing that the classic “crushing chest pain” is just as atypical as “atypical” symptoms of shortness of breath, abdominal pain, or weakness, especially in women or the elderly.) And what if it’s suspicious? What’s the “appropriate recommendation?” Go see your cardiologist? Go back to your primary care doctor? Get a stress test with a 70-80% sensitivity (thereby missing 20-30% of patients with significant coronary disease)?

The recommendation, of course, is simple. According to Dr. Kirsch’s office (which I just called), here it is: “If this is a life-threatening emergency, hang up and dial 911.” To be taken by an ambulance — likely under the direction of an emergency physician — to be evaluated by … an emergency physician.

If an ER physician, or any doctor, thinks his patient’s abdominal discomfort is from constipation, then treat it accordingly and arrange for proper follow-up in the office.

Uh, trust me, we do. I disimpact with the best of them and give enemas when appropriate. But when it’s an elderly patient with a chief complaint of “constipation,” you better be damn well sure of your diagnosis: abdominal pain in the elderly has a 10% mortality rate. And they’re also classic for having 5-7 days of abdominal pain that turns out to be an appendicitis. Funny how they present like that. (Also: “follow-up in the office?” How about our 45 million uninsured patients who lack an “office” to follow-up in?)

Let’s play a numbers game, too.

  • Emergency care costs less than 3% of the nation’s 2.1 trillion dollar health care expenditures. That’s 63 billion dollars.
  • I don’t know what percentage of care Dr. Kirsch considers excessive, but even if all emergency care is excessive, then that means only 3% of medical care is excessive. (If that’s all, I’d say 97% with a purpose is pretty good!)
  • Using some back of the envelope numbers from the 2002 Journal of Gastroenterology, if today we’re doing 20 million colonoscopies at $1,000 a pop, that’s almost 1% of all health care expenditures, just to put that in some perspective for the GI folks out there. Ahem.
  • I’ll concede one point to Dr. Kirsch: I see a lot of “innocent complaints” in the Emergency Department. It’s our nature, thanks to EMTALA. When EMTALA was passed, we certainly started seeing more patients with non-emergent complaints, but now the two are all mixed together and it’s often difficult to tell them apart. If some other physicians are willing to step in and offload the emergency department of some of our patients with “innocent complaints,” please, go right ahead!

    (I didn’t think so.)

    Until then, we’ll continue having the proud duty of caring for all patients with all complaints all hours of the day.

    It’s really easy for everyone to call bullshit on the Emergency Department (my motto: you’re not getting out of here without a troponin!) when they have the benefit of days, weeks, or even just a few hours of observing the patient. Or some basic labs, or an EKG. But there’s no way in hell I’m going to stop putting the dangerous diagnoses in my differential alongside the more common ones. I’d ask Dr. Kirsch where he’d go if a loved one had, say, a bicycle injury. Would he be satisfied with a history and physical and a quick discharge home with a diagnosis of “contusion?” Of course not. When it’s your loved one, you want the x-ray to rule out the fracture. (As I’ve written before, often the physical exam just isn’t that hot.)

    Until I start critiquing polypectomy skills or demanding an endoscopy outside of normal business hours, it’s probably best that you stick to the GI tract, Dr. Kirsch.

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