Emergency Department Use and Enrollment in a Medical Home Providing After-Hours Care

Kiran and colleagues demonstrated that patient affiliation with one of Ontario's various reformed models of primary care with after-hours service was not associated with reduced emergency department visits in comparison with the rest of the Ontario population. This is an important finding to guide policy makers as they seek to improve health system performance. Or is it?

Why do we want to reduce emergency department (ED) visits? Perhaps each non-emergent ED visit represents a missed opportunity for primary care treatment or prevention.[1] Or perhaps not.[2,3] Reducing ED visits is definitely an expression of patient and provider values and preferences. Or definitely not.[4] Maybe care in EDs is somehow inferior to other ambulatory care, results in overtesting or adverse events, or undermines the benefits from continuity of care.[5-8] Or maybe not.[9] Certainly ED care is more costly than other forms of ambulatory care, especially for conditions that could be treated in a variety of ambulatory settings.[10] Or not certainly.[11] Surely ED overcrowding and wait times could be addressed by diverting care to other more appropriate settings. Or not surely.[12] Reducing ED visits might seem desirable, but perhaps it does not stand up to scrutiny as a health systems or primary care goal.

So why are policymakers focussed on reducing ED visits? One possibility is that counting ED visits is easier to do with administrative health data than evaluating the quality of primary care. While it is much easier to manage what you can measure, the ability to measure something does not mean you must manage it.

Unfortunately, a focus on volume of ED visits may distract from more meaningful targets. Like it or not, emergency departments are part of the primary care ecosystem. ED staff are trained to care for patients with non -acute problems -- many have extensive primary care training and experience. Patients choose to seek care in the ED for a variety of complex reasons. Sometimes because they can't access their medical home. Sometimes they are medically home-less.[13,14] Patients rarely come to the ED with the expectation that they will get inferior care. ED staff don't approach their non-acute patients as if they represent an adverse event. When patients present to the ED (whether by choice or out of necessity), researchers, policymakers, and providers need not treat it as a system failure.

Rather than assessing each ED visit as an adverse event, let's talk about transitions of care between various parts of the ambulatory care system, including family practices and emergency departments but also dentists, physiotherapists, pharmacists and more. Let's collaborate to deliver better care across all ambulatory care settings, and let's evaluate that system together. Let's shift our focus from counting visits to measuring the coordination and integration of care.

[1]Billings J, Parikh N, Mijanovich T. Issue brief no. 434 -- emergency department use: the New York story. New York: The Commonwealth Fund, November 2000 (http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2000/Nov/Emergency%20Room%20Use%20%20The%20New%20York%20Story/billings_nystory%20pdf.pdf).
[2]Johnson PJ, Ghildayal N, Ward AC, Westgard BC, Boland LL, Hokanson JS. Disparities in potentially avoidable emergency department (ED) care: ED visits for ambulatory care sensitive conditions. Medical care. 2012 Dec 1:1020-8.
[3]Hsia RY, Niedzwiecki M. Avoidable emergency department visits: a starting point. International Journal for Quality in Health Care. 2017 Oct 1;29(5):642-5.
[4] Uscher-Pines L, Pines J, Kellermann A, Gillen E, Mehrotra A. Deciding to visit the emergency department for non-urgent conditions: a systematic review of the literature. The American journal of managed care. 2013 Jan;19(1):47.
[5] Gill JM, Mainous III AG, Nsereko M. The effect of continuity of care on emergency department use. Archives of family medicine. 2000 Apr 1;9(4):333.
[6] Christakis DA, Mell L, Koepsell TD, Zimmerman FJ, Connell FA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001 Mar 1;107(3):524-9.
[7] Kanzaria HK, Hoffman JR, Probst MA, Caloyeras JP, Berry SH, Brook RH. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging. Academic Emergency Medicine. 2015 Apr;22(4):390-8.
[8] Forster AJ, Rose NG, van Walraven C, Stiell I. Adverse events following an emergency department visit. BMJ Quality & Safety. 2007 Feb 1;16(1):17-22.
[9] Dale J, Green J, Reid F, Glucksman E, Higgs R. Primary care in the accident and emergency department: II. Comparison of general practitioners and hospital doctors. Bmj. 1995 Aug 12;311(7002):427-30.
[10] Campbell MK, Silver RW, Hoch JS, Ostbye T, Stewart M, Barnsley J, Hutchison B, Mathews M, Tyrrell C. Re-utilization outcomes and costs of minor acute illness treated at family physician offices, walk-in clinics, and emergency departments. Canadian Family Physician. 2005 Jan 1;51(1):82-3.
[11] Williams RM. The costs of visits to emergency departments. New England Journal of Medicine. 1996 Mar 7;334(10):642-6.
[12] Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Annals of emergency medicine. 2008 Aug 1;52(2):126-36.
[13] Howard MS, Davis BA, Anderson C, Cherry D, Koller P, Shelton D. Patients' perspective on choosing the emergency department for nonurgent medical care: a qualitative study exploring one reason for overcrowding. Journal of Emergency Nursing. 2005 Oct 1;31(5):429-35.
[14] Masso M, Bezzina AJ, Siminski P, Middleton R, Eagar K. Why patients attend emergency departments for conditions potentially appropriate for primary care: reasons given by patients and clinicians differ. Emergency Medicine Australasia. 2007 Aug;19(4):333-40.

Competing interests: None declared