Underestimation of Disease

Severity by Emergency

Department Patients :

Implications for Managed Care

Jeffrey M. Caterino, M.D. C. James Holliman, M.D., F.A.C.E.P. Penn State University College of Medicine M. S. Hershey Medical Center Hershey, Pennsylvania, U.S.A.

Study Background

ƒ E.D.'s often criticized for having high % of "inappropriate" visits

ƒ Current attempts by managed care to screen patients' symptoms via phone prior to approving E.D. visit–Is this practice safe ?

Study Background :Findings from Prior Studies

ƒ 1980 ACEP study :–12 % of patients rated urgency of their condition lower than did the doctor–25 % of patients rated by doctor as needing urgent care thought they could wait–4 % judged by doctor to be more urgent in retrospect–Concluded : " Inappropriate utilization of E.D.'s appears to be more a perceptual issue than a real one"

Study Background :Other Prior Studies

ƒ 1985 study : only 10 % inappropriate visitsƒ All earlier studies were retrospective & had

"non- emergent" visits mostly around 40 % (6 to 81 %)

ƒ Elderly have low rates of "inappropriate" visits

ƒ 1996 followup study (to the 1980 ACEP study) showed same % severity assessments by patients & doctors as in 1980 study

ƒ 1996 Pittsburgh study : 6 % of Medicaid patients denied E.D. approval proved emergent

Current StudyObjectives

ƒ Determine differences in symptom severity assessment by E.D. patients and by emergency physicians (E.P.'s)

ƒ Correlate these assessments with case management and disposition

Study Setting

ƒ M. S. Hershey Medical Center E.D.

ƒ University Hospitalƒ Rural, suburban settingƒ Annual census 28,000ƒ 20 % pediatric casesƒ Level 1 trauma centerƒ Staffed by faculty E.P.'s &

residents

Study Design and Participants

ƒ Prospective convenience sample of E.D. patients

ƒ Included :–All E.D. patients registered when first author in E.D.–Both day & night shifts–May to August 1996

ƒ Excluded :–Patients treated by major trauma response team–Patients with psychiatric chief complaint

Study Methods

ƒ All patients interviewed by first author & asked to class their Sx as emergent, urgent, or nonurgent

ƒ E.P. attending asked to class patients' Sx after initial exam, and again after workup was complete

Study Methods :Definitions of Acuity

ƒ Emergent–Care needed in < 1 hour

ƒ Urgent–Care needed within 6 hours

ƒ Nonurgent–Care could safely wait > 24 hours

Study Results

ƒ Total cases : 301ƒ Male / female : 151 / 150ƒ Age < 12 : 13 %ƒ Age > 65 : 16 %ƒ Referred to E.D. by health care

professional : 37 %

Study Results

Patient's Self - Classification

% Emergent Urgent Non- urgent

%Admitted

Emergent 13 44 44 12 46

Urgent 60 10 55 35 27

Non- urgent

27 4 31 65 5

E.P.'s post - workup classification (%) (of the 3 groups in column 1)

Study Results The "Non-urgent" Patient Self-Classed Group (n = 83)

ƒ 43 male, 40 femaleƒ 7 % age < 12, 6 % age > 65ƒ 40 % referred by health care

professionalƒ E.P.'s initial class : E.P.'s final

class :–Emergent : 2 3–Urgent : 38 26–Non-urgent : 43 54

ƒ Admitted : 4 (5 %)ƒ Class upgraded : 4 (5 %)

Comparison of Results to Prior Studies

ƒ % "non-urgent" self-assessed by patients was higher (27 vs. 13 %)

ƒ Similar % (35 vs. 33) of patients assessed by E.P. as needing emergent or urgent care in the non-urgent self-assessed group

ƒ Retrospective (post-workup) E.P. assessments down-class (17 %) more than up-class (5 %) case severity

Study Limitations

ƒ Relatively small number of patients

ƒ One hospital & geographic areaƒ 3 scale rather than 5 scale

severity usedƒ Case denominator altered by

exclusion of major trauma & psychiatric patients

Study Conclusions

ƒ 5 % of study patients self-rated as non-urgent required hospital admission

ƒ 35 % of patients self-rated as nonurgent were rated higher severity by E.P.

ƒ Another 5 % of patients rated by E.P. had severity upgraded after workup

ƒ Patient severity self-classification allows prediction of chance of admission ( Emergent : 46 %, Urgent : 27 %, Nonurgent : 5 %)

Relevance of Study to Managed Care

ƒ A significant % of patients with self-assessed minor symptoms may have serious illness and require urgent care

ƒ Screening of these patients by phone to deny E.D. visit approval is unsafe (for at least 5 %)

ƒ Even after screening exam, 5 % of cases are upgraded in severity by the E.P.

ƒ Even prospective severity assessment does NOT identify "unnecessary" E.D. visits

Further Studies Needed

ƒ Larger numbers of patients in different E.D.'s in different geographic areas

ƒ Should record case assessment both prospectively (pre-workup) and retrospectively (post-workup)

ƒ Need to track carefully emergent treatments and post-admission care