Emergency Department Use by Primary Care Patients at a Safety-Net Hospital FREE

In fee-for-service payment models, there are strong financial incentives for hospitals to tolerate high levels of emergency department (ED) use, including use by established primary care patients. Yet, as health care reform introduces global payment models, high levels of ED use will no longer be financially tenable. Understanding the magnitude of the problem of ED use by established primary care patients is crucial to redesigning primary care delivery and reimbursement in the United States. We had 2 objectives: (1) to characterize ED use at an urban safety-net hospital after the implementation of Massachusetts health reform, focusing on patients who had primary care providers (PCPs) and (2) to identify patterns of ED use that might inform the hospital-based primary care practices' transformation to a medical home, and eventually, to an accountable care organization.

Boston Medical Center (BMC) is an urban safety-net hospital with 8 primary care practices staffed by 105 PCPs. The practices predominantly serve a minority and low-income population. We identified patients who had 1 or more primary care visits from July 1, 2009, to July 1, 2010, and examined their ED use over this period. We defined frequent ED users as patients with 4 or more ED visits in the past year and occasional ED users as those with 1 to 3 ED visits in the past year. We used an algorithm developed by Billings et al¹ to categorize each visit's principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and to determine the probability that a visit required ED care. Using a validation of this algorithm,² we defined visits as high severity if the probability that ED care was needed was 0.75 or higher for the visit's principal ICD-9-CM diagnosis. Similarly, we defined visits as low severity if the probability that ED care was needed was 0.25 or lower. Visits of indeterminate severity were defined as those with a probability higher than 0.25 and lower than 0.75. Visits classified as high severity have been found to have a strong association with future hospitalization or death.³ We performed χ² tests and t tests to compare differences in demographics between persons with and without any ED use and with occasional vs frequent ED use. The Boston University Medical Campus institutional review board has approved this study as exempt.

During the study period (2009-2010), 39 603 patients had 1 or more primary care visits. Most patients (65.4%) did not make any ED visits, while 11 787 (29.8%) were occasional ED users and 1928 were frequent ED users (4.9%) (Table). The 11 787 patients with occasional ED use made 17 759 visits over the study period, while the 1928 patients with frequent ED use made 12 289 visits. Approximately half (49.8%) of all ED visits occurred on weekdays, while BMC primary care practices were open. Most ED visits were for low-severity conditions.

Emergency department use by primary care patients at an urban safety-net hospital was high, though most visits were of low severity. One possible reason for this is lack of access to primary care,⁴ with few available appointments to see a PCP. While data on time to third next available appointment, a standard measure of primary care access,⁵ are not available for the primary care practices during the study period, other practice metrics suggest that access may have been a problem. For example, missed primary care appointment rates were high, averaging 24.5%. High missed appointment rates are often correlated with long wait times to schedule appointments.⁶ In addition, monthly telephone call statistics show that only between 72.4% and 88.1% of patient telephone calls were answered by the primary care call center over the study period. It is possible that patients called the practices with an urgent problem, did not have their telephone call answered promptly, and decided to seek care in the ED instead. Indeed, 13% of telephone calls were abandoned by patients over the study period (patients called and subsequently hung up while they were kept on hold). The fact that nearly half of all ED visits took place during the hours of primary care clinic operation further suggests that appointment availability may have been an issue. In addition, a sizable minority, roughly one-fifth, of primary care is provided by residents,⁷ who have limited availability when they are not in clinic. It is also possible that Massachusetts health reform has affected access to primary care. As newly insured patients have entered primary care in large numbers, it is possible that access to primary care has worsened for other patients.

Massachusetts has been a bellwether for the implementation of health reform and will be a bellwether for the transformation of primary care, with the move away from fee-for-service payments and the introduction of global payments for health care. Overall ED volume has continued to increase in Massachusetts after health reform.⁸ It is unclear if changes in primary care practice and payment will be sufficient to reduce high levels of ED use among patients at an urban safety-net hospital.