Brian J. Zink, M.D.: On those 'preventable' hospital emergency department visits

This previously ran in The Providence Journal and on cmg625.com

Consider this real-life situation: A 65-year-old Rhode Islander has high blood pressure and high cholesterol. Saturday evening after dinner, he develops crushing pain in his chest and nausea. His wife is alarmed and wants to call the rescue to take her husband to the local hospital emergency department (ED). (Note: The term “ER” is widely used, but antiquated given that many EDs now contain over 50 rooms.)

But, as he struggles with the pain, he remembers reading about a report from the Rhode Island Executive Office of Health and Human Services and HealthSource RI claiming that 60 percent of ED visits were preventable, and that for Medicare patients the leading “preventable” ED visit was for chest pain. So, he thinks, “I don’t need to go to the hospital, it’s probably just ingestion.”

Wrong. As the chest pain worsens, a good portion of this man’s heart muscle, deprived of blood and oxygen from a blocked coronary artery, is irreparably damaged. He is left with only half of his normal heart function. Over the next few weeks, his activity level and health declines. He develops heart failure, an irregular heartbeat, and requires frequent hospitalizations and stays in the ICU. He needs a pacemaker. His quality of life is poor and he dies prematurely from heart-related complications.

Let’s look at the health economics of this case. If this gentleman had been seen in the ED with his initial bout of chest pain, his heart attack would have been diagnosed within 10 minutes, and within 90 minutes a stent could have been placed by a cardiologist to open up his blocked artery. He would have near normal heart function and would have been discharged within 48 hours.

With good medical management by his primary-care doctor and cardiologist, he would live a long life, free of cardiac symptoms, and yet he would consume far fewer medical resources than in the above scenario. The total cost of not visiting the ED, in this case, is likely to be more than 10 times higher than an appropriate ED visit with expedient care and follow-up.

The data that HealthSource RI uses appears to assume that if a patient’s presenting complaint did not result in an admission to the hospital, then the visit was preventable. That “Monday-morning-quarterback” approach is fraught with risk. Policy makers should not interfere with or misinform patients’ decision-making about when to seek emergency care for serious symptoms. That approach is also frequently penny-wise and pound foolish. Symptoms that could be a heart attack, a stroke, or a ruptured aneurysm should be evaluated and treated as true emergencies. That is good medical practice, and also financially smart when downstream costs are considered.

The state also assumes that a primary-care physician or clinic is readily available as an alternative to the “unnecessary” ED visit. As many citizens of Rhode Island will attest, trying to get prompt access to primary care, especially after hours or on weekends, is very challenging. And with a serious symptom like chest pain in a 65-year-old, a call to the primary-care office will usually get this appropriate response: “Go to your nearest hospital ED."The cost of emergency care is estimated to represent about 6 percent to 8 percent of total health-care expenditures in the United States. Emergency care is not the place to get a real “bang for the buck” in reducing costs in healthcare. The effect on overall healthcare spending of eliminating every “inappropriate” ED visit would be minimal.

Certainly, some ED visits could be avoided with proper planning, communication and access to alternative care sites. Those of us who work in EDs are actively engaged in innovative approaches that will hopefully lead to more coordinated, efficient, and less expensive medical care.

Better communication with primary-care physicians and patient-centered medical homes, increased case management in the ED, and increased observation services to avoid admissions are all part of ongoing projects. These are more sensible ways to reduce costs than to encourage patients with serious symptoms to avoid emergency care.

Brian J. Zink, M.D., is president of University Emergency Medicine Foundation (UEMF), a Rhode Island group practice.