Thursday, May 2, 2013

The Most Common Reasons for Unnecessary Pediatric ER Visits (And Why We Should All Care)



A large proportion of pediatric ER visits do not involve true emergencies. These children would better be served by their own physician in the office setting. But the number of children receiving part or all of their primary care in the hospital emergency room is growing. This should be a concern to all of us for several reasons. First, unnecessary visits clog up emergency departments, so if you or your family members have a true emergency there is the risk of delayed treatment, even when a good system of triage is maintained. Secondly, a majority of children receiving substantial care from ERs for trivial problems receive government sponsored insurance which is paid by all of us. Whereas an office visit might cost the taxpayer about fifty bucks, the same care in an ER usually saddles the tax payer with a bill for around $1,000. And perhaps most importantly, the ER is a poor place to receive primary pediatric care: the patient is seen by a different physician every time; the physician does not have access to important aspects of the child’s medical record; no follow-up or continuity of care can be provided.
            So why do so many families rely on Emergency departments for the medical care of their children? There are many reasons but these are by far the most common.
1.      A perceived emergency. We often deal with routine childhood illnesses that are not emergencies but are perceived as such by parents. This, in my view, is a perfectly appropriate reason to go to the ED but should be remedied by providing education and what is known as anticipatory guidance. The most important part of the education is to advise parents that, with the exception of trauma, poisonings, severe allergic reactions or respiratory distress they should phone their doctor’s office before going to the Emergency Room to receive advice and triage.
2.      Travel. For families on a trip away from home (particularly those who have government funded health insurance) the hospital ER is the only alternative to obtain care.
3.      Lack of insurance. In many cases this involves a lapse of Medicaid due to not complying with the renewal requirements. If you have no insurance and no independent financial means, you will not be seen in doctor’s offices or free-standing clinics, but the ER cannot refuse to provide care.
4.      Unavailability of primary care providers. This sounds ridiculous, but some physicians will close their offices for extended periods of time and not provide reasonable alternative coverage. Their coverage is the local ER. More frequently, the office is open but the doctor refuses to see a “sick” patient. The child has a high fever? Go to the ER. She has a tummy pain? Could be appendicitis. Go to the ER. Yes, it might be appendicitis, but you can’t possibly form a reasonable judgment unless you examine the child. And if it is, you might spare a wait in the ER and arrange for the child to be directly admitted to the hospital.
5.      Referrals from primary care provider. The emergency department has become a major destination for referrals in many cities. I have been referred patients for problems related to growth and even for dermatological problems. This is a waste of everyone’s time and an inappropriate use of resources. The thinking from the referring physician is that once the child is in the hospital, the ER doctor will make the proper referral, or a specialist will materialize in the ER out of thin air.
6.      Convenience. For families with working parents it is difficult to get to a doctor’s office if it does not have extended hours. The ER, on the other hand, is always open. It is disheartening to see how often families bring in three or four children at the same time. One child is ill, they explain, and they want to take the opportunity to just get the other kids checked out even though they’re feeling just fine.
7.      Second opinion. Many of the kids we see in Emergency Rooms have already seen one or more physicians for their child’s illness – often the very same day. They come to the ER to ask if the treatment provided by their own doctor is reasonable and appropriate, or because they haven’t noticed an improvement in their child’s ear infection after the first dose of antibiotic.
8.      Desire for specialty care. The family has already seen their physician who has reached a diagnosis and may or may not have instituted a plan of treatment but then the family decides they want a specialist to see the child. They register in the ED with the expectation that ENT, orthopedics, dermatology and endocrinology will see their child in the emergency room for a non-urgent problem. Not only will the specialist not see the child in the ER, the ER doctor may not be able to provide the desired referral because many health plans require the primary care doctor to submit this request for approval.
Children deserve to receive their medical care in a medical home; from a physician who knows the child and the family and is available to provide continuity of care. We all deserve Emergency Rooms that are not so bogged down in the management of trivial problems that when a true emergency happens our loved ones are able to receive immediate attention by professionals providing the care they were trained to provide.
            There is no simple fix to this problem, but certainly it must include a change in paradigm in the financing of care. Charging a small co-pay to Medicaid patients for ER visits is likely to assuage its use out of sheer convenience without discouraging appropriate visits. Altering payment patterns for physicians is also essential. Medicaid re-imbursement for sick visits is so low that it hardly is worth the effort to many pediatricians. It is imperative that patients, physicians and policy makers work together to find solutions or we will all suffer the consequences.

4 comments:

  1. So what's the solution?

    To break the cycle, I believe two fundamental things have to change:

    1. ERs should be able to turn away non-urgent patients, after appropriate triage. They should be explicitly instructed to followup with their primary during regular hours and sent packing if ER care is clearly unnecessary.

    2. There must be a cost to the family, high enough to discourage unnecessary visits, but not so high as to discourage genuine trips. That will need to be some kind of sliding scale. I'm not smart enough to figure out how to do that, but I imagine a computer model could.

    Good post!

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    Replies
    1. I completely agree with both of your thoughts! I think a triage nurse should be able to assess a pt and determine if they need to be seen any further (maybe triage should be backed by an NP?).
      Also I was thinking while reading the article that co-pay should be based on diagnosis. Example, if Dx is viral syndrome they should have a higher charge, but if Dx is trauma, resp distress etc. then it should be a standard ER co-pay.

      Either way, great article!

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  2. This is a great information for many parents. However, in some instances, it is really important to go to pediatrics Dallas for further recommendations that your child needs.

    ReplyDelete
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    ReplyDelete