2014 myresearch. SCIENCE Internship Program

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3 2014 myresearch SCIENCE Internship Program

4 Lyndsi Powell Science Internship Program

5 A Qualitative Survey of the Correlation Between Patient-Doctor Communications and Referrals Into the Emergency Department Lyndsi Powell Baruch Fertel, MD, MPA Sharon Mace, MD, FACEP, FAAC

6 Background The amount of patients in the ED has increased for several reasons. Previous studies demonstrate that elderly patients with a Primary Care Physician (PCP) visit the ED infrequently 4. Studies from other countries suggest that those without access to PCP s visit the ED more often 1. Other studies suggest that approximately 50% knew their complaint could have been addressed in an alternate venue, but chose the ED 3.

7 Hypothesis The increase in patients visiting the ED was potentially thought to be a result of patients using the ED as a source for primary care. It is probable that the majority of the participants did not attempt to contact any other physician before their ED visit, thus arriving without referrals from medical professionals.

8 Abstract Determine the reason behind which patients increasingly visit the ED for issues that could be treated by a PCP. Convenience survey was created to establish patient interactions with other physicians prior to ED visits. Although most patients had PCP s, less than half attempted to contact other physicians. It is essential in urban areas to encourage the contact of other physicians before going to the ED.

9 Methodology Direct face-to-face survey instrument consisting of six patient-answered questions. Information regarding demographics and triage level of acuity were collected from the EMR. IRB approved; exempt from informed consent. Kept in a HIPAA certified manner. Convenience sample. Patients with stable mental state. Patients extremely ill (Triage Level 1) exempted.

10 Limitations Single care site (CCF Main Campus Emergency Department). Quaternary level hospital with integrated health system. Public Hospital in an urban area (Cleveland, Ohio). Convenience sample. Day hours. week days (Mon-Thurs). Ages 18+.

11 Data 467 patients were approached; 364 agreed to participate. 21 of the patients were employees and were exempted from the data because they were referred by colleagues with medical backgrounds. This left 343 patients as the data pool. The surveys were answered by patients, family members and friends of patients.

12 Data Triage Level refers to the relative level of pain a patient feels on a specific scale created by The Cleveland Clinic.

13 Data Demographic Statistics of Patients referred and self-referred by physicians. Referred Not Referred/ Self-Referred Age: Mean STD Median Gender : Male 65/145 (44.83%) Race: Black: 175/343 (51.02%) Female 80/145 (55.17%) 48/145 (33.10%) 88/198 (44.44%) 110/198 (55.56%) 127/198 (64.14%) White: 156/343 (45.48%) Other: 12/343 (3.50%) 92/145 (63.45%) 5/145 (3.45%) 64/198 (32.32%) 7/198 (3.54%)

14 Data Referred Not Referred/ Self Referred Contacted MD prior to ED 117/139 (84.17%) 22/139 (15.83%) visit Have a PCP: 277/ /277 (46.93%) 147/277 (53.07%) (80.76%) Last saw PCP: 252/277 were referred or selfreferred. Less than 3 months ago 98/252 (38.89%) 107/252 (42.46%) Between 4-12 months ago 12/252 (4.76%) 19/252 (7.54%) More than 1 year ago 10/252 (3.97%) 6/252 (2.38%)

15 Results Of the 343 consenting patients, only 143 (41.69%) contacted a medical professional prior to their visit to the ED. Only 145/343 (42.27%) of the patients arrived with medical referrals. However, 277/343 (80.76%) of the patients had PCP s.

16 Conclusions These findings support the former assumption that most patients in the ED come without professional recommendation, however a significant minority arrive with referrals. The data also serves as evidence that the majority did not contact other physicians before deciding to visit the ED. However, the data discredits the belief that most patients lacked a PCP given that over 80% did indeed have a PCP.

17 Recommendations Conducting a survey that is not a convenience sample. Differing the time of day, including weekends, and encompassing community/suburban hospital surveys as well. Understanding why medical providers referred the patients. Determining if the referrals were appropriate for the issue at hand.

18 References 1. Carret, M. L. V., Fassa, A. G., & Kawachi, I. (2007). Demand for emergency health service: Factors associated with inappropriate use. BMC Health Services Research, 7(131) 2. Derlet, R. W., & Richards, J. R. (2000). Overcrowding in the nation's emergency departments: Complex causes and disturbing effects. Annals of Emergency Medicine, 35(1), Grumbach, K., Keane, D., & Bindman, A. (1993). Primary care and public emergency department overcrowding. American Public Health Association, 83(3), Hastings, S. N., Whitson, H. E., Sloane, R., Landerman, L. R., Horney, C., & Johnson, K. S. (2014). Using the past to predict the future: Latent class analysis of patterns of health service use of older adults in the emergency department. Journal of the American Geriatrics Society, 62(4), Liu, S. W., Nagurney, J. T., Chang, Y., Parry, B. A., Smulowitz, P., & Atlas, S. J. (2013). Frequent ED users: Are most visits for mental health, alcohol, and drug-related complaints? The American Journal of Emergency Medicine, 31(10), McWilliams, A., Tapp, H., Barker, J., & Dulin, M. (2011). Cost analysis of the use of emergency departments for primary care services in charlotte, north carolina. North Carolina Medical Journal, 72(4), Schuur, J. D., & Venkatesh, A. K. (2012). The growing role of emergency departments in hospital admissions. New England Journal of Medicine, 367(5), Taubman, S. L., Allen, H. L., Wright, B. J., Baicker, K., & Finkelstein, A. N. (2014). Medicaid increases emergency-department use: Evidence from oregon's health insurance ex[eriment. American Associate for the Advancement of Science, 343(6168), Wharam, J. F., Zhang, F., Landon, B. E., Soumerai, S. B., & Ross-Degnan, D. (2013). Low-socioeconomic-status enrollees in high-deductible plans reduced high-severity emergency care. Health Affairs, 32(8),

19 Special Thanks To Dr. Fertel, my primary mentor who taught me so many invaluable lessons and kept learning fun. Dr. Mace, my co-mentor who aided me with data analysis and compilation. Morgan Jennings, my partner who worked alongside me throughout the duration of the 9 weeks. Cleveland Clinic Main Campus Emergency Department Staff who allowed my partner and I to carry out our research without any problems.

20 Special Thanks To Office of Civic Education Initiatives.

21 Copyright 2014 Cleveland Clinic Foundation

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