ER doc: to better understand why patients return to the emergency room…ask them

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    There’s been a lot of discussion in health care about how to keep people out of the hospital and curb the use of expensive care that may be better delivered elsewhere or avoided altogether.

    The Centers for Medicare and Medicaid, for example, now penalizes hospitals that have comparably high rates of patients who are readmitted to the hospital within 30 days.

    As a researcher, Dr. Kristin Rising, director of acute care transitions at Thomas Jefferson University Hospital, has wanted to know, readmitted or not, what drives some patients to return to the emergency room so soon after an initial visit.

    She says researchers and policy makers have been crunching data, spending “a lot of time thinking about why patients come back, and what might we do to change that,” but they rarely ask the patients themselves.

    So she did. Rising conducted 60 in-depth interviews with people who came back within nine days to the emergency departments at either the Hospital of the University of Pennsylvania or Penn Presbyterian Medical Center.

    Fear and anxiety a unifying theme

    Dr. Rising had expected to hear a lot about social problems – struggles with child care, for example, or even getting transportation to the doctor’s office – as main reasons for patients returning to the ER. But that wasn’t the case.

    “The most unifying thing that they did express regardless of their specific situation at home was that they were afraid,” she says.

    Symptoms may not have entirely resolved, she says, or new ones surfaced since the initial visit, making patients more anxious. As one example, she recalls a patient saying, ‘I don’t know what’s a stroke, but I know reading up on symptoms that you have, I would rather be safe than sorry.”

    Another patient started bleeding in the middle of the night and was scared to be alone.

    And while the majority of patients did have insurance and a primary care doctor they liked, they didn’t know where else to go for quick answers.

    “So that’s why I wanted to come back to the emergency room,” she heard time and time again.

    “The biggest takeaways are patients are scared, and they need more reassurance throughout their health care process,” she says. “They don’t trust the current outpatient system to be responsive enough and quick enough in addressing their needs.”

    Creating a more responsive outpatient care system

    The study has some key limitations. All the patients were concentrated in one geographic area, and it didn’t include the alternate perspective of those who did not return to the ER.

    Even so, the study resonated a lot with Dr. Jeffrey Brenner, who focuses on similar questions across the river in Camden, as director of the Camden Coalition of Health Care Providers.

    “If a patient believes that something terrible is happening inside of them, it’s a fairly reasonable thing in their mind at that moment to go to the emergency room,” he says, as opposed to possibly getting put on hold with a primary care office, waiting weeks for an appointment and then having to follow up with referrals for tests. “We’ve made emergency rooms very accessible and easy to go to.”

    In Camden, he says the top reason patients reportedly came to the ER over a 5 year period was for head colds.

    Brenner cautions that what drives health behavior can be varied and complicated, so he hopes to see more research that builds on Rising’s approach, incorporating sociology and anthropology methods to go out and learn directly from patients in their own words. “We need to figure out what true north is before we can solve a problem.”

    But both he and Rising say this latest study indicates that solutions to people returning to the ER may be found in developing better systems for primary and outpatient care, one that includes improved communication and more accessible services. That way, they say, patients can ask questions and seek guidance when and where they need it.

    Rising says some tangible approaches could include expanded walk-in clinics, doctor availability outside the typical 9-to-5 workday, and the use of technologies to bridge communication gaps between visits.

    “We should shift that blame away from patients and into the health care system,” she says. “Until we have a more available and flexible health care system, it is absolutely in the patients eyes to come to the hospital when they are doing so. And therefore it is an entirely appropriate visit in their eyes.”

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