In review of ED utilization reduction strategies, data regarding impact on safety, outcomes in short supply
Emergency providers need a seat at the table’ in discussions about ED utilization going forward
In an effort to drive down costs, health care organizations have focused intently in recent years on developing strategies to curb ED utilization. While some of these strategies have been based in the ED, there have also been a number non-ED based interventions. However, what remains unclear is not just which of these strategies are most effective, but also whether they are associated with unintended consequences. (Also see "Any changes in ED utilization hinge on delivery system reform," p. 10)
It’s an issue of high importance to ED providers and policy makers alike, particularly as the health reform law ushers in changes intended to give many more people access to coverage and care. It is not yet apparent whether large numbers of newly insured patients will cause ED volumes to spike, as they did initially in Massachusetts when that state implemented health reform a few years ago. Nevertheless, to gather added insight on what is known about ED-utilization reduction strategies, investigators looked at the available evidence regarding five types of non-ED-based interventions, including:
• patient education;
• patient financial incentives;
• the creation of additional non-ED capacity;
• pre-hospital diversion;
• managed care.
The investigators conducted a systematic review of 39 studies, including 34 that were observational and five that were randomized controlled trials.1 What they found was that interventions that can be broadly categorized as patient education were associated with the greatest magnitude of reductions, but this does not necessarily mean that educational strategies offer more potential to reduce ED use than the other types of interventions, according to co-author Jesse Pines, MD, MBA, MSCE, director of the Office of Clinical Practice Innovation and professor of emergency medicine at George Washington University School of Medicine and Health Sciences in Washington, DC.
"To say that education is more effective than other types of interventions is probably a stretch just because the interventions were so heterogeneous," says Pines. "But the most effective intervention we found was actually an educational intervention that involved giving patients information about ear infections in kids, and also giving parents specific medicine that can help with the symptoms of ear infection to reduce the need for a face-to-face visit."
Notably, none of the educational interventions studied involved general education about when to use the ED versus clinics or primary care physicians (PCP) a type of intervention that figures prominently in Washington state’s well-publicized efforts to reduce ED utilization. "We were looking at specific clinical conditions," says Pines.
Currently in vogue:
Managed care interventions
The interventions categorized as using patient financial incentives mainly consisted of putting financial barriers in place between patients and the ED. "Having higher copays was the main thing," says Pines. And these types of interventions clearly had an impact on ED use. "The early study on that is the Rand Health Insurance Experiment, where [investigators] gave patients variable copays for ED visits, and the patients who had zero copays had the highest ED use," says Pines.2
Interventions that involved creating additional non-ED capacity typically involved the opening of urgent care centers and retail clinics, or moves to extend the hours of PCPs. In general, what the investigators found from these types of interventions was that they had the effect of increasing overall demand for care. "If you open up a new health care establishment, people will come there. The question is are these replacements for ED visits, or are these patients who wouldn’t have been seen [in the ED]," says Pines. "What one study [from Ireland] found was there was some degree of supply-induced demand, so if you open up a new establishment, more people will come and your overall volume will increase, although you will get some degree of substitution, but it is pretty small."3
The studies looking at pre-hospital diversion primarily involved expanding the scope of practice for paramedics so that they could potentially interface with medical command and release people in the field or, alternatively, take patients to alternative sites rather than the ED, explains Pines. "These interventions can potentially be effective, but there really isn’t a lot of evidence behind this yet," he says.
Managed care interventions involved providing financial incentives to PCPs to see patients in a timely manner, and some of these efforts were effective, explains Pines. "This is one of the major interventions that is going on now with accountable care organizations," he observes. "It is a new way of paying physicians outside of the hospital where the assumption is that by delivering more efficient care, people will use the ED less."
Data on safety, outcomes still needed
While most of the interventions reviewed had at least some success in reducing ED utilization, Pines observes that missing from most of these studies were data regarding the impact on clinical outcomes. "The major issue is patient safety. There are a lot of ways you can discourage patients from coming into the hospital by creating economic barriers for them or creating logistical barriers for them in seeking care," he says. "Creating barriers will certainly have the effect — and this is what we found — of reducing utilization, but the question is whether people who actually need to be seen in the ED are not being seen because those barriers are being erected."
Very few of the studies reviewed or even assessed whether clinical outcomes were changed as a result of the interventions, says Pines. "In most of the studies, it was more of a rarity that any clinical outcomes were mentioned." However, as health care reform unfolds, along with shared-savings models and accountable care organizations, Pines sees safety and clinical impact as high on the list of metrics that will be monitored. The hope is that such innovations will provide patients with better access to care and better managed care without producing negative consequences.
"Creating economic barriers has the impact of potentially harming people who are already disadvantaged," stresses Pines. "To some people, a $50 or $100 copay may not matter, but to a lot of people it might, and those people will have less access to other outpatient venues."
Time to fully engage
Whether utilization reduction strategies are based in the ED or in other settings, Pines stresses that ED providers need to be fully engaged in how they are structured. "A lot of times people who work outside of the ED don’t really understand what happens in the ED, so I think having a seat at the table will allow us to argue why having EDs open is valuable, and what value we add to the system," he says. "I think among people who don’t work in the ED, that [value] is very under-appreciated."
Another factor that may be under-appreciated is the fact that emergency providers are problem solvers, says Pines. "With the new payment models, there will be a lot of new delivery mechanisms that will both facilitate new access to care, but also could potentially create additional problems. And when those problems arise, I think emergency physicians are going to be asked to participate in solutions," he says. "The message for emergency physicians is to get a seat at the table, participate in the process, and then figure out ways that the unique skills of emergency physicians can add value to these new models."
- Jesse Pines, MD, MBA, MSCE, Director, Office of Clinical Practice Innovation, and Professor of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC. Phone: 202-994-4128.
- Morgan SR, Chang AM, Alqatari M, Pines J. Non-emergency department interventions to reduce ED utilization: A systematic review. Acad Emerg Med. 2013;20:969-985.
- O’Grady KF, Manning WG, Newhouse JP, Brook RH. The impact of cost-sharing on emergency department use. N Engl J Med. 1985;313:484-490.
- O’Kelly FD, Teljeur C, Carter I, Plunkett PK. Impact of a GP cooperative on lower acuity emergency department attendances. J Emerg Med. 2010;27:770-773.