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Underestimation of Disease Severity by Emergency Department Patients :

Underestimation of Disease Severity by Emergency Department Patients : Implications for Managed Care. Jeffrey M. Caterino, M.D. C. James Holliman, M.D., F.A.C.E.P. Penn State University College of Medicine M. S. Hershey Medical Center

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Underestimation of Disease Severity by Emergency Department Patients :

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  1. Underestimation of Disease Severity by Emergency Department Patients : Implications for Managed Care Jeffrey M. Caterino, M.D. C. James Holliman, M.D., F.A.C.E.P. Penn State University College of Medicine M. S. Hershey Medical Center Hershey, Pennsylvania, U.S.A.

  2. Study Background • E.D.'s often criticized for having high % of "inappropriate" visits • Current attempts by managed care to screen patients' symptoms via phone prior to approving E.D. visit • Is this practice safe ?

  3. Study Background : Findings from Prior Studies • 1980 ACEP study : • 12 % of patients rated urgency of their condition lower than did the doctor • 25 % of patients rated by doctor as needing urgent care thought they could wait • 4 % judged by doctor to be more urgent in retrospect • Concluded : " Inappropriate utilization of E.D.'s appears to be more a perceptual issue than a real one"

  4. Study Background : Other Prior Studies • 1985 study : only 10 % inappropriate visits • All earlier studies were retrospective & had "non- emergent" visits mostly around 40 % (6 to 81 %) • Elderly have low rates of "inappropriate" visits • 1996 followup study (to the 1980 ACEP study) showed same % severity assessments by patients & doctors as in 1980 study • 1996 Pittsburgh study : 6 % of Medicaid patients denied E.D. approval proved emergent

  5. Current Study Objectives • Determine differences in symptom severity assessment by E.D. patients and by emergency physicians (E.P.'s) • Correlate these assessments with case management and disposition

  6. Study Setting • M. S. Hershey Medical Center E.D. • University Hospital • Rural, suburban setting • Annual census 28,000 • 20 % pediatric cases • Level 1 trauma center • Staffed by faculty E.P.'s & residents

  7. Study Design and Participants • Prospective convenience sample of E.D. patients • Included : • All E.D. patients registered when first author in E.D. • Both day & night shifts • May to August 1996 • Excluded : • Patients treated by major trauma response team • Patients with psychiatric chief complaint

  8. Study Methods • All patients interviewed by first author & asked to class their Sx as emergent, urgent, or nonurgent • E.P. attending asked to class patients' Sx after initial exam, and again after workup was complete

  9. Study Methods : Definitions of Acuity • Emergent • Care needed in < 1 hour • Urgent • Care needed within 6 hours • Nonurgent • Care could safely wait > 24 hours

  10. Study Results • Total cases : 301 • Male / female : 151 / 150 • Age < 12 : 13 % • Age > 65 : 16 % • Referred to E.D. by health care professional : 37 %

  11. Study Results E.P.'s post - workup classification (%) (of the 3 groups in column 1) Patient's Self - Classification % Emergent Urgent Non- urgent % Admitted Emergent 13 44 44 12 46 Urgent 60 10 55 35 27 Non- urgent 27 4 31 65 5

  12. Study Results The "Non-urgent" Patient Self-Classed Group (n = 83) • 43 male, 40 female • 7 % age < 12, 6 % age > 65 • 40 % referred by health care professional • E.P.'s initial class : E.P.'s final class : • Emergent : 2 3 • Urgent : 38 26 • Non-urgent : 43 54 • Admitted : 4 (5 %) • Class upgraded : 4 (5 %)

  13. Comparison of Results to Prior Studies • % "non-urgent" self-assessed by patients was higher (27 vs. 13 %) • Similar % (35 vs. 33) of patients assessed by E.P. as needing emergent or urgent care in the non-urgent self-assessed group • Retrospective (post-workup) E.P. assessments down-class (17 %) more than up-class (5 %) case severity

  14. Study Limitations • Relatively small number of patients • One hospital & geographic area • 3 scale rather than 5 scale severity used • Case denominator altered by exclusion of major trauma & psychiatric patients

  15. Study Conclusions • 5 % of study patients self-rated as non-urgent required hospital admission • 35 % of patients self-rated as nonurgent were rated higher severity by E.P. • Another 5 % of patients rated by E.P. had severity upgraded after workup • Patient severity self-classification allows prediction of chance of admission ( Emergent : 46 %, Urgent : 27 %, Nonurgent : 5 %)

  16. Relevance of Study to Managed Care • A significant % of patients with self-assessed minor symptoms may have serious illness and require urgent care • Screening of these patients by phone to deny E.D. visit approval is unsafe (for at least 5 %) • Even after screening exam, 5 % of cases are upgraded in severity by the E.P. • Even prospective severity assessment does NOT identify "unnecessary" E.D. visits

  17. Further Studies Needed • Larger numbers of patients in different E.D.'s in different geographic areas • Should record case assessment both prospectively (pre-workup) and retrospectively (post-workup) • Need to track carefully emergent treatments and post-admission care

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