An Inappropriate Truth

This month's Annals of Emergency Medicine has a series of articles on ED usage, plus an editorial entitled, "Frequent ED Visitors: The End of Inappropriateness." Given the tenor of posts from seasoned ED bloggers, I expected this editorial would be about denial-of-care protocols, full of anecdotes about abusive patient freeloaders.

But in fact, this editorial is based on evidence. The one anecdote included is a doozy, about a father who took his infant to the ED, got a diagnosis of OM, but his insurance denied payment due to the "inappropriateness" of the visit. The father, of course, was the board-certified EM physician who wrote the editorial.

He goes on to delineate the separate but related complaints of overcrowding, frequent flyers, and inappropriate ED use, which he defines as follows:

Generally defined as an ED visit by someone with a nonurgent or less-urgent condition treated more efficiently and cheaply in an office or clinic setting. In its more malignant form, inappropriate ED use has been characterized as visits by people of lower socioeconomic status who are "gaming" the system by claiming benefits and services to which they are not entitled...

...In this issue of Annals, 2 articles provide compelling evidence that the "inappropriate" ED visit is nothing of the kind.

Dr. Bernstein concludes his piece:

The notion of the "inappropriate" ED user is largely apocryphal. Fuda and Immekus and Hunt et al convincingly demonstrate that frequent ED users are sicker, with considerable mental illness and substance use, than infrequent or nonusers. Frequent ED users come to the hospital because they need care. Infrequent users may avoid the ED with expanded access to primary care, but this is not at all clear. Constructive policy change will not result from a blame-the-victim analysis.

Perhaps a wiser health policy goal would be to focus on the delivery of high-quality, convenient, accessible care to all patients in all clinical settings, ambulatory, emergency, and inpatient. Intensive case management of frequent ED users and expanded off-hours access to facilities delivering primary care, especially mental health and substance use treatment, may decrease the frequency of ED recidivism, but additional work is needed to test the efficacy of these interventions. In health care's current political climate, which emphasizes cost containment and personal responsibility, it is difficult to see this happening. But for now, let us put to rest future conversations about "inappropriate" ED use.

Sadly, I don't think Dr. Bernstein's recommendations will be heeded in ED conference rooms and EM blogs. I, too, have been guilty of letting the stress get to me, generalizing from one encounter to an entire waiting room. But I've also made a conscious effort to adopt well-conducted new research into my practice, and these findings should be no different.