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Preventive care poses dilemma for emergency departments

27.09.2010
People go to emergency departments when they've broken a leg, been stabbed or otherwise need urgent care. But a new study from the Stanford University School of Medicine finds that 90 percent of EDs nationwide also offer preventive-care services.

The high prevalence was surprising, said M. Kit Delgado, MD, the study's lead author and a postdoctoral scholar at Stanford's Center for Primary Care and Outcomes Research, and it likely stems from less-than-ideal conditions.

"It's more evidence that our health-care system is dysfunctional," said Delgado, who is also an emergency-medicine physician at Stanford Hospital & Clinics. "Emergency departments have evolved to compensate as the 'safety net' for patients failed by a system unable to guarantee accessible primary care."

Indeed, the study, to be published online Sept. 27 in the Annals of Emergency Medicine, illustrates a dilemma faced today by many emergency departments: the desire to address underlying illnesses and unhealthy behaviors without compromising the quality of acute care, which is their primary mission.

It is the first known study to provide an overall picture of the scope of preventive care in U.S. emergency departments, measuring the availability of 11 such services - including influenza vaccinations, counseling for tobacco addiction and screening for HIV - in 277 randomly sampled EDs from 46 states. The median number of preventive services offered was four.

At 66 percent, screening for domestic violence was the most common, though the study points out that it probably should have been higher. The Joint Commission, the major accrediting agency for U.S. health-care organizations, mandates hospitals and clinics to have policies and procedures for this type of screening. The figure suggests that many EDs may not be in compliance.

At 19 percent, HIV screening was the least common service. The U.S. Centers for Disease Control and Prevention released guidelines in 2006 recommending HIV tests be done at EDs.

There is some incentive for EDs to offer preventive services. "Basically, it's about how 'an ounce of prevention is worth a pound of cure,' and we try to do all we can for patients," said Robert Norris, MD, chief of emergency medicine at Stanford Hospital, who was not involved in the study. "One thing that is notable about emergency medicine is that we are often presented with teachable moments. So, for example, people who come in with an alcohol-related injury - we can discuss with them why this happened and how much worse the consequences could have been, and then help to get them set up in a treatment program."

Stanford Hospital's ED is ahead of the curve, providing about a half-dozen innovative preventive services, including:

The award-winning nurse callback program, which helps discharged patients to coordinate follow-up appointments and get access to primary or specialty care.

A public insurance enrollment program (run in collaboration with San Mateo County) that has enabled thousands of children to get insurance since it began in 2004.

"Farewell to Falls," a free, home-based fall-prevention program for older adults that was recognized in 2007 by the Home Safety Council and National Council on aging.

In addition, doctors and nurses in the ED screen patients for domestic violence and alcohol abuse and offer intervention services through ED social workers.

But echoing a major finding of the study, Norris said that cost is a key factor determining which and how many preventive services can be offered at Stanford's ED. "When you're in a resource-constrained environment, you have to pick and choose," he said.

For example, Delgado cited two key factors that discourage EDs from offering HIV tests: One, they add to unreimbursed costs, and two, studies have shown that, if mandated, they can result in longer waiting times for patients.

Sixty-four percent of ED directors expressed concern that preventive services would increase patients' length of stay, leading to overcrowding.

While three-quarters of ED directors surveyed do not oppose offering preventive services, the same number worries that doing so could financially hurt their departments. The government and insurance companies do not reimburse emergency departments for the cost of most preventive services, Delgado said. "Our findings imply that more widespread dissemination of ED preventive services will likely be contingent on improved reimbursement," the authors write in the study.

Delgado referred to recent reports in the Journal of the American Medical Association and from the U.S. Department of Health and Human Services that find patients with poor access to primary care, even those with insurance, are the largest rising segment of the patient population showing up at EDs.

Unsurprisingly, a system to link emergency department patients with primary care providers topped the wish list among directors, followed closely by a system to cover uninsured patients with some form of medical insurance.

The authors conclude that more research is needed on the cost-effectiveness of ED preventive services, as well as on their effect on patient flow, to help determine the best way to invest ED resources.

Ultimately, however, emergency departments are not well-designed for providing preventive care, Delgado said.

"The goal for health-care reform should go beyond increasing access to health insurance to ensuring that primary care is actually accessible," he said. "This would free up ED resources to handle rising volumes of patients for acute care visits and would ensure that benefits from prevention efforts are sustained over the long run."

Other Stanford co-authors are Colleen Acosta, MPH; Ewen Wang, MD; Matthew Strehlow, MD; and Yash Khandwala. Carlos Camargo Jr., MD, DrPH, of Harvard Medical School, is the senior author.

The study was supported with a training grant from the Agency for Health Care Research and Quality Training and a mentored research award from the National Institutes of Health. Information about the Center for Primary Care and Outcomes Research and the Department of Medicine, which also supported the research, is available, respectively, at http://healthpolicy.stanford.edu/ and http://medicine.stanford.edu/.

The Stanford University School of Medicine consistently ranks among the nation's top medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit http://mednews.stanford.edu. The medical school is part of Stanford Medicine, which includes Stanford Hospital & Clinics and Lucile Packard Children's Hospital. For information about all three, please visit http://stanfordmedicine.org/about/news.html.

John Sanford | EurekAlert!
Further information:
http://www.stanfordmed.org

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