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Andrew P. Wilper, Steffie Woolhandler, Karen E. Lasser, Danny McCormick, Sarah L. Cutrona, David H. Bor, and David U. Himmelstein Waits To See An Emergency Department Physician: U.S. Trends And Predictors, 1997–2004 Health Affairs, March/April 2008; 27(2): w84-w95. [Abstract] [Full Text] [Figures Only] [PDF] [Appendix Table] [Reprints & Permissions]

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Electronic letters published:

Additional Considerations For Wait Times

Patricia Merryweather   ( 16 January 2008 )

Change In The Practice Of Emergency Medicine Affects Patients' Waiting Times

Neal Devitt   ( 28 January 2008 )

Who Practices In The ER?

Julie Graves Moy, MD, MPH, PA   ( 21 April 2008 )

Additional Considerations For Wait Times 16 January 2008
Patricia Merryweather, Senior Vice President Hospital Association Send letter to journal: Re: Additional Considerations For Wait Times pmerryweather{at}ihastaff.org Patricia Merryweather	While I fully agree with all the conditions cited for delays in emergency rooms, I would encourage you in the next study to consider the wait times due to meeting the insurer requirements. Delays in getting insured patients to an inpatient setting or to observation care have considerably added to the delays in getting patients through to the proper treatment. Also, consider the hundreds of pages from both federal and private insurers that identify the conditions for a patient admission -- review the AMI, heart failure, pneumonia conditions and you will find the detailed decision-making processes that go on to decide whether or not the patient qualifies for being sick enough for a level of care that a physician thinks is appropriate. And then also consider that pending the Medicare fiscal intermediary or the commercial insurer, the requirements vary among payers or intermediaries. When I started in health care 20 years ago, the percent of inpatients going through the ED was about 25%, and that was viewed as being way out of line -- way too many utilizing the ED for source of admission. The situation today now has, depending upon payer, 55% to 75% of all patients going through the ED for inpatient admissions. Also, consider another phenomenon -- the observation care patient. In Illinois a few years ago, we had about 20K to 30K patients classified as observation care. Now we are averaging over 300K per year -- these are all patients who were admitted into observation care from the ED. Remember, observation care is the location patients are placed when they cannot be admitted to an inpatient setting due to not meeting insurer requirements and they are too sick and unstable to be sent home. They go to observation care, which is typically in an inpatient bed, and stay any time up until 72 hours following admission to observation care. I think you have touched the tip of the iceberg -- but there is much more beneath the surface. Keep up the great work -- and let me know if you need any follow-up information.
Change In The Practice Of Emergency Medicine Affects Patients' Waiting Times 28 January 2008
Neal Devitt, Senior Physician La Familia Medical Center, Santa Fe, NM Send letter to journal: Re: Change In The Practice Of Emergency Medicine Affects Patients' Waiting Times ndevitt{at}earthlink.net Neal Devitt	I have practiced in a community health center in Santa Fe, New Mexico, for the past 23 years. For much of that time I saw my own patients when they presented to the emergency room. As well, for 5 years I worked part time in an emergency room in a near by community. During those years I have seen a marked change in the practice of emergency medicine. It is rare now for an emergency physician to use a Bayesian probability approach to the diagnosis of chest pain and send the patient with a low pretest probability of cardiovascular disease or pulmonary embolus home without a sestimibi scan or a CT pulmonary angiogram or both. For the patient with abdominal pain, a CT scan is almost de rigueur. Conversely, diagnosis and disposition solely on the basis of a physical exam is a lost art. A child or adolescent with abdominal pain requires an abdominal CT scan with contrast in the ER rather than a physical evaluation by a surgeon or a discharge home with a plan to be reexamined the next day by the patient's physician, even when the patient has easy access to a primary care physician. As a result, I have seen a patient of mine present to the ER, get an abdominal CT scan, and be admitted for further evaluation without ever getting a rectal exam in the ER -- an exam on the floor showed heme positive stool and led to the diagnosis of a duodenal ulcer. Every day primary care physicians see patients in the office with chest pain, abdominal pain, and other acute complaints, which I understand are associated with a risk of legal liability. Yet we are able to plan a disposition for many of these patients without a CT scan. I believe that this change in the practice of emergency medicine results in part from the change in staffing of emergency rooms so that most are staffed only with emergency medicine-trained physicians. While this benefits the care of the critically ill patient,these physicians have little or no exposure to the outpatient practice of medicine where they could learn that in some cases they could rely solely on physical exam and history for diagnosis or plan a next-day follow-up instead of an abdominal CT scan with contrast. This would aid "throughput," save resources/money, and relieve me of the burden of reviewing a ream of paper with test results when I see the patient in follow-up.
Who Practices In The ER? 21 April 2008
Julie Graves Moy, MD, MPH, PA, Physician Institute for Health Policy, Univ of Texas School of Public Health Send letter to journal: Re: Who Practices In The ER? juliegravesmoy{at}gmail.com Julie Graves Moy, MD, MPH, PA	For many patients, the hours of available physician care in the ER make care in this setting more accessible. Americans work long hours, often have no sick leave, and often find that employers do not tolerate leaving work for a physician visit. ER care is often the only alternative to job loss or child care problems. Emergency medicine as a specialty is relatively new, and has a four-year curriculum mostly in the ER, without substantial time in primary care experiences. As a board-certified family physician who has chosen inpatient hospitalist and emergency medicine practice, I find that my training and experience in family medicine residency and then in practice provide me with appropriate skills and training to handle the clinical situation in the ER. And, for the care of acutely ill children, obstetric problems, and "primary-care seekers in the ER," I believe that I have better training than those who only trained in the ER setting. However, I am limited to practice in smaller, usually rural ERs, and cannot practice in larger, busier urban ERs that are short-staffed and could use my help. Why? I am board-certified in family medicine but not in emergency medicine. There are not enough board-certified emergency medicine physicians in the U.S. to cover all of the ER shifts, and many Texas ERs find it very difficult to cover shifts 24/7/365. Why can I not sit for the emergency medicine board exam, with my board certification in family medicine and 16 years of experience in hospital and ER care? Why must I spend four years in an emergency medicine residency to sit for this examination? If we want to staff ERs adequately, and meet the needs of American who need to access medical care at the time they can do so without losing their jobs, we need to allow internists, pediatricians, and family physicians who have adequate experience to sit for the ABEM exam without going back to a second residency. Then we can cover ER shifts, care for the primary care seekers, and handle the crisis care we can also provide competently after our primary care training and ongoing continuing education.