Health care costs in the United States are projected to rise steadily.1 This will greatly affect Americans, especially with rising inflation, and ultimately will lead to delayed primary care and chronic care management. This promotes scenarios in which patients seek care in an acute setting at the hospital and in the emergency department (ED), as opposed to continuously maintaining their conditions. New solutions are needed to align incentives, especially as we move toward global payment and value-based care models, such as the Medicare Access and CHIP Reauthorization Act, quality-based payment programs, and accountable care organizations. To better reduce costs and provide optimum care to the American population, there needs to be better alignment of incentives between the acute care setting in hospitals and outpatient practices.
Although the coronavirus disease 2019 pandemic initially saw a decline in ED volume, an increase in ED boarders and acuity has led to significant crowding, stasis, and delays in care, even in pediatric EDs.2 Associated with a myriad negative effects on both patients and physicians, ED crowding leads to medical errors, increased mortality, physician burnout, poor patient satisfaction, and inefficient use of resources, which ultimately leads to downstream effects on the inpatient side, including longer hospital length of stay (LOS).3 Pediatric ED crowding has also been shown to be the strongest predictor of patients leaving without being seen by a provider (LWBS).4 This is of concern because an estimated 13% to 18% of LWBS patients had problems serious enough to require immediate attention, with many of these patients returning to the ED within 1 week.3 Furthermore, ED crowding also increases the odds of admission and inpatient LOS.5,6 Together, patients LWBS typically return with higher acuity, leading to further increased inpatient LOS. The cycle continues to worsen as hospitals fill with increased acuity and longer stays, which leads to further ED crowding and boarding, and an endless spiral. For example, the diabetic child that is now in diabetic ketoacidosis, instead of just being hyperglycemic, now must board in the ED during their return visit.
Estimates of adult EDs reveal that between 13.7% and 27.1% of ED visits could be provided at an alternate site, potentially saving $4.4 billion a year.7 The exact financial impact on pediatric EDs is still unclear. All of this points to a need to focus on interventions that reduce ED utilization and ED crowding, which ultimately will improve clinical outcomes, patient satisfaction, and the value of care delivered.
Strategies for Reducing ED Crowding
To decrease ED crowding, hospitals can focus on either reducing the actual number of patients seeking care in the ED, or reducing the patients’ LOS’s and improving efficiency of the department.8 Previous strategies explored to reduce the number of patients who present to the ED include financial incentives, increased access to primary care, prehospital diversion, educational initiatives, and better managing the care of patients with complex medical and social situations.9 The use of “patient navigators,” who guide and assist high-risk patients with maintenance and follow-up upon discharge from the ED, has also been explored.10 Although successful short term, a personal patient navigator program may not be cost-effective, and positive effects are not consistently sustained.10,11 Increased pharmacist/other caregiver engagement and additional behavioral health supports in communities may also decrease ED utilization and subsequent admissions.3 Improved access to primary care is a popular point of intervention that has shown some success.3 Strategies to reduce ED LOS include improving “throughput” and “output” mechanisms; for example, nurse-initiated order sets at triage or streamlining hospital admissions with centralized, active bed management.12 A combination of increased access to primary care, patient education, and chronic disease management interventions are regarded among the safest, most effective, and most sustainable strategies.13,14 Our suggested intervention sharpens the focus of increasing access to outpatient clinicians by emphasizing the role of specialists in chronic disease management.
Reducing ED Utilization Through Specialist Involvement to Reduce Hospitalizations
For many patients with chronic or complex disease, the relevant specialists become primary caregivers. Specialist involvement is thus paramount in considering how to reduce ED utilization by these patients.13,15 One strategy to identify patients most in need of support, and ultimately reduce the number of patients presenting to the ED, may be the use of targeted and actionable feedback to outpatient specialist clinicians regarding ED use by their patients.7,16,17 The reports showed how each specialist’s ED use rate differs from those colleagues in their practice group and were thus called “ED Use Variation” reports. Such reports were distributed to divisional leadership and to individual physicians. Viewing the reports and comparing the practice patterns and patient characteristics of high and low outliers helped specialists identify families who struggle with home care and/or chronic disease management. The specialist departments could then discuss and develop initiatives to address the needs of these patients and families before they turned to the ED. For example, pediatric pulmonology used nurses to “call back” patients who were deemed high risk after discharge from the hospital.7 Similarly, pediatric gastroenterology began routinely booking patients who called the practice with urgent complaints to be seen rapidly.17,18 Overall, the key is that the outpatient clinical groups knew their patients and were able to design interventions on the basis of the data from the reports.7
This approach appeared to be effective at reducing ED use rates.7,17 Over 2 years, ED use reports led to a 60% decrease in gastrointestinal-related ED visits, declining from 4.89 ED visits per 1000 office visits to 1.95 ED visits per 1000 office visits, which was correlated with report use and program creation.17 Similarly, these same trends were seen among pediatric neurology. On cost analysis, these reduced ED visits lead to overall cost savings of an estimated $104 c500 in 2017.19 On longitudinal follow-up of our initial intervention, the reduction in ED use was sustained and robust over time.20
Conclusions
We believe that the use of the reports helped specialists identify patients, patterns of patient problems, and practice patterns at the level of the individual doctor and at the level of their practice or division that were associated with potentially unnecessary or avoidable ED use and ultimately reduce hospitalizations and hospital LOS. This allowed the specialists to develop programs that provided increased access to routine and non-ED urgent visits for selected patients and patients with groups of problems. This increased access helped patients receive outpatient rather than ED care, and reduced ED volumes and costs.20 There were no reported safety or patient care concerns with our program; however, there was the unintentional consequence of adding further burden to our outpatient specialists in their already busy practice environment.7,17
Our findings suggest that the generation and distribution of ED use variation reports among the most common ED visit-related specialties would be a simple and effective intervention to decrease pediatric ED utilization, hospitalizations, and cost. This strategy is limited in that it is best fit for tertiary-care centers, or when the patient’s specialist and ED are within the same care network. In the future, it may be worthwhile to investigate the use of ED variance reports among other specialties, and to compare the interventions of each. Hospitals and EDs with crowding issues should consider exploring variation reports of ED utilization to reduce ED use and provide hospital care in a more cost-efficient manner. Ultimately, with a movement toward global payment and value-based care models, the need to align hospital/ED-based incentives with outpatient programs will only become more urgent.
Acknowledgments
We thank Wally Balk for his support.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLAIMER: Dr Lee consults for Butterfly Network, Inc, and has unrelated grant support from Beckman Coulter, Inc, and Nihon-Kohden Corporation. Dr Lee is also an advisor for Covid Act Now, a non-profit supporting COVID information to the public and is the founder of Health Tech Without Borders, a non-profit, global, NGO supporting Ukraine with Telemedicine.
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