More US patients going to emergency rooms as alternative to primary care, report says

BMJ 2013; 346 doi: (Published 23 May 2013) Cite this as: BMJ 2013;346:f3398
  1. Michael McCarthy
  1. 1Seattle

US emergency physicians are increasingly being called on to provide services to patients who lack access to primary care, to evaluate complex outpatient cases, and to serve as gatekeepers to hospitals, a new report has concluded.1

The report was produced by the RAND Corporation, an independent, non-profit policy research organization that is based in Santa Monica, California, and was commissioned by the Emergency Medicine Action Fund, an advocacy organization founded by the American College of Emergency Physicians.

RAND officials said that the research was conducted independently and that the study’s sponsor had no control over the study or its findings.

The report notes that over the past decade the capabilities of emergency departments have expanded as their staffing has shifted from part time coverage by community physicians and “moonlighters” to 24 hour coverage by residency trained, board certified emergency physicians who are capable of managing a wide range of complex problems.

Today, as well as providing emergency care to critically ill and injured patients, emergency departments are being called on to perform outpatient evaluation of complex cases and are handling overflow, after hours, and weekend coverage for office based physicians, the report says.

“Almost all of the physicians we interviewed—specialist and primary care alike—confirmed that office-based physicians increasingly rely on EDs [emergency departments] to evaluate complex patients with potentially serious problems, rather than managing these patient themselves,” the RAND researchers wrote.

Emergency physicians have also become the key decision makers in almost half of hospital admissions, the report found.

Noting that inpatient care accounts for 31% of US healthcare spending, the role of the emergency physician as gatekeeper had “important financial implications,” the report said.

Although the proportion of patients entering hospitals through the emergency department has been rising, evidence exists that emergency departments are preventing some unnecessary admissions, the report said. In particular, although emergency department visits for conditions such as asthma and diabetes rose from 2003 to 2009, “the overall rate of potentially preventable admissions due to these conditions did not,” the report said. “Our analysis strongly suggests, but cannot conclusively prove, that EDs may be helping to constrain the growth of preventable hospital admissions.”

The report also found that most patients coming to emergency departments were seeking primary care services, most of whom were doing so because “no viable alternative exists, or because a healthcare provider sent them there.”

The findings “suggest that efforts to reduce non-urgent visits to EDs should focus on assuring timely access to primary care, rather than blocking access to EDs,” the researchers wrote.

Given the number of roles that hospital emergency departments now had in the US healthcare system, “hospital administrators, policymakers, payers, and federal research agencies should pay closer attention to ED operations, particularly the role that EDs play in facilitating needed hospital admissions and avoiding those that are preventable,” the researchers concluded.


Cite this as: BMJ 2013;346:f3398