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The emergency room at a Madeira, California, hospital in a 2004 photo. (AP)

Fewer emergency rooms but more patients

COMMENTARY | February 25, 2008

In recent years several hundred emergency departments (EDs) closed around the U.S., while the total number of patient visits soared. A 2008 study showed waits to see the ED physician increased 36% between 1997 and 2004. The government's answer: cut funding for urban hospitals, where waits are longest.

By Andrew Wilper

Americans are waiting longer to see the doctor when they visit the emergency department (ED). Even patients who are severely ill, such as those with heart attacks and those thought to have a condition threatening life or limb, are waiting longer for medical attention. These were among the conclusions of a study carried out by a team of Harvard Medical School researchers at the Cambridge Health Alliance, of which I was the lead author. The study, released in January, analyzed over 90,000 ED visits nationwide.

ED crowding has drawn some attention in recent years. A 2006 report, for example, found that one ambulance per minute is diverted in the U.S. due to overcrowding. This is a story that reporters and editors everywhere in the U.S. may want to dig into, regardless of the size of their community or their news organization.

Severely ill patients suffered the largest increases in ED waits. Between 1997 and 2004, waits increased 36 percent for all patients (from 22 minutes to 30 minutes, on average). However, for those whom a triage nurse classified as needing immediate attention, waits increased by 40 percent (from 10 to 14 minutes). Waits increased the most for emergency patients suffering heart attacks, who waited only 8 minutes in 1997, but 20 minutes in 2004, a 150 percent increase. A quarter of heart attack victims in 2004 waited 50 minutes or more before seeing a doctor. 

Q. Why are waits increasing?

General overcrowding likely plays a large role. Between 1994 and 2004, 12 percent of EDs closed, while the number of visits to EDs increased nearly 20 percent. A phenomenon known as “boarding”, where patients wait in the ED for a hospital bed because all of the hospital’s beds are full is increasingly common and often causes bottlenecks in the Emergency Departments (also commonly referred to as emergency rooms).

Q. Are the findings of your study surprising?

Perhaps not. Given the drop in the number of EDs (several hundred nationwide over the past decade), we might expect that those remaining would be less able to care for patients, even the severely ill. ED doctors and other advocates have been trying to get the public’s attention about this problem for years. The Institute of Medicine published Hospital Based Emergency Care: At the Breaking Point (free online) in 2006 in order to draw attention to a system in crisis.

Q. Other than increasing resources allocated to Emergency Departments, could regulatory interventions help reverse these trends?

Absolutely. In fact, in 2004, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) tried to institute a rule requiring hospitals to decrease crowding and boarding. Buckling to hospital industry protests, JCAHO withdrew the rules.  Increasing the availability of alternatives to the ED for nonurgent care (i.e., primary care physicians) would also help unload the system.

Q. What is the federal government doing to help reverse these problems?

Remarkably, the federal government plans to cut funding to strained urban hospitals that care for the largest proportion of Americans that also have the longest waits. This is surprising given the massive attention given to homeland security after September 11, 2001. It is not clear that medical safety net will be able to handle a man made or natural disaster if it is straining to care for “routine” emergencies.

Q. Some have argued that curbing uninsurance would not reduce ED overcrowding. Do you agree?

Uninsured people did not increase their use of the ED during the study period, so we can’t blame their behavior for lengthening ED waits. Nonetheless, universal national health insurance could decrease ED crowding. Part of the reason people use the ED is because they have nowhere else to go. If we insured more people, they would have options such as seeing doctors in offices or clinics and use the ED less. This would be doubly beneficial: 1) by decreasing nonurgent use and 2) by reducing complications of routine illnesses (like diabetes, heart failure, and asthma) that, when left untreated, can have catastrophic consequences. These conditions are better cared for outside of the emergency department where doctors and patients can establish relationships over time.   

Q. There seem to be financial incentives in the ED. Can you expand on that?

Emergency departments can be chaotic; patients there are sick, often with complex illnesses. Furthermore, they cannot be screened for health insurance. Hospitals do not receive extra payment for admissions through the emergency room. In this system, patients admitted through the ED are often money losers for hospitals. By contrast, other arenas in hospital medicine can be very lucrative. For example, a hospital can schedule multiple elective surgeries per day on patients with insurance, which is very profitable. The incentives set up by this system are clear.

Q. Do you think recent immigrants are driving these trends?

No, in fact, we know that recent immigrants use less health care on average than do others in the United States. The idea that immigrants are causing the crisis in American medicine, including the crisis in emergency rooms, is urban myth. When our group looked nationally at the use of medical care, we found that immigrants used, on average, only half as much care as the native-born. This study, led by Dr. Sarita Mohanty, appeared in the American Journal of Public Health, and has never been challenged.

Focusing on immigrants as ‘the straw that broke the camel’s back' may be politically popular at the moment, but doing so distracts from the roots of the problem: 1) a financing system that leaves millions without health insurance and that undervalues primary care, and 2) hospitals closing EDs in response to this financing system, or limiting inpatient hospital beds for patients admitted through the ED.

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