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Restricting ED Access Endangers Medicaid Recipients, Researchers Say

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In a recent study, patients who were escorted to and assigned a personal physician on the hospital's premises increased their contact with primary care physicians over the space of a year but did not significantly decrease how often they visited the emergency department. 

Despite strict guidelines on which patients were classified as "non-urgent," 10 patients were ultimately admitted to the hospital, according to the results of a study published online in the Annals of Emergency Medicine ("An Intervention Connecting Low Acuity Emergency Department Patients with Primary Care: Impact on Future Primary Care Linkage"). 

"[EDs] can be ideal places to initiate public health interventions such as linking patients to primary care, but connecting patients to primary care is just the first step," says lead study author Stephen Wall , MD, MSc, of the Department of Emergency Medicine at Bellevue Hospital Center in New York City.

"Even with a primary care clinic onsite at our hospital, the intervention was not foolproof as shown by the number of so-called 'non-urgent' patients who ended up admitted to the hospital," Wall notes. "If anything, our study underscores the danger of cost-cutting measures proposed by state Medicaid agencies and other insurers who would restrict 'non-emergency' ER use."

At a public safety-net hospital in New York City, 965 non-emergent ED patients were enrolled in the study, with 191 patients assigned to receive treatment in the ED and 662 assigned to receive treatment in the onsite primary care clinic. 

Patients were eligible for inclusion if they came to the ED with problems that a layperson would be likely to identify as non-emergent (examples included sore throat or simple urinary tract infection). 

The patients assigned to the primary care clinic were escorted there by a patient navigator and assigned to a primary care physician. Patients who lacked health insurance were enrolled in the hospital's fee-scaling plan or public insurance if they were eligible.

The intervention resulted in a 9.3 percent absolute improvement in primary care follow-up, though the decrease in ER visits was not statistically significant.

Four patients from the primary care clinic group were ultimately admitted to the hospital for reasons that included homicidal thoughts and endocarditis (inflammation of the heart lining).

"Attempts to decrease non-urgent ER use, particularly among patients who are already low users of the emergency department, are unlikely to significantly decrease ER crowding or costs," says Wall.  "It is important that the definition of what is 'an emergency' remain in the hands of patients. However, increased primary care access might result in improved care for chronic health conditions affecting millions of people, which could lead to long-term cost savings."

Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians.  For more information, visit www.acep.org.


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