Cowling, Thomas E

Majeed, Azeem

LSHTM Research Online

Cowling, TE; Majeed, A (2013) Overuse of emergency departments.JAMA, 309 (24). p. 2549. ISSN 0098-7484 DOI: https://doi.org/10.1001/jama.2013.6933Downloaded from: http://researchonline.lshtm.ac.uk/4503986/DOI: 10.1001/jama.2013.6933Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Copyright the publishersWe submit that the contribution of myocardial fibrosisto risk reclassification is therefore more precisely gaugedfrom the individual components of the NRI (ie, the net pro-portions of patients correctly reclassified among those withand without the outcome).6 This information is summa-rized in our reclassification tables and in the Comment sec-tion of the article.Ankur Gulati, MDTevfik F. Ismail, MDSanjay K. Prasad, MDAuthor Affiliations: Royal Brompton Hospital, London, England (s.prasad@rbht.nhs.uk).Conflict of Interest Disclosures: The authors have completed and submitted theICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Gulati reportedreceiving grants fromCORDA, Rosetrees Trust, and the National Institute for HealthResearch. Dr Ismail reported receiving grant support from the British Heart Foun-dation. Dr Prasad reported receiving grant support from the British Heart Foun-dation, CORDA, Rosetrees Trust, and the National Institute for Health Research;and receiving speaking fees from Bayer Schering.1. McMurray JJ, Adamopoulos S, Anker SD, et al; ESC Committee for PracticeGuidelines. ESC guidelines for the diagnosis and treatment of acute and chronicheart failure 2012: the Task Force for the Diagnosis and Treatment of Acute andChronic Heart Failure 2012 of the European Society of Cardiology: developed incollaborationwith the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012;33(14):1787-1847.2. Levy WC, Linker DT. Prediction of mortality in patients with heart failure andsystolic dysfunction. Curr Cardiol Rep. 2008;10(3):198-205.3. Ismail TF, Prasad SK, Pennell DJ. Prognostic importance of late gadolinium en-hancement cardiovascular magnetic resonance in cardiomyopathy. Heart. 2012;98(6):438-442.4. Pfisterer M, Buser P, Rickli H, et al; TIME-CHF Investigators. BNP-guided vssymptom-guided heart failure therapy: the Trial of Intensified vs Standard Medi-cal Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) ran-domized trial. JAMA. 2009;301(4):383-392.5. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporatedinto the ACC/AHA 2005 guidelines for the diagnosis and management of heartfailure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in col-laboration with the International Society for Heart and Lung Transplantation.Circulation. 2009;119(14):e391-e479.6. Pepe MS. Problems with risk reclassification methods for evaluating predictionmodels. Am J Epidemiol. 2011;173(11):1327-1335.Overuse of Emergency DepartmentsTo the Editor:As in the United States, the overuse andmis-use of emergency departments (EDs) is a prominent policyissue in England. The annual number of hospital ED visitsin England increased from15.4million in 2007-2008 to 18.4million in 2011-2012.1 The patient was given advice onlyor did not receive treatment in approximately 48% of theseED visits, and no investigations were performed in approxi-mately 40% of ED visits.1Dr Adams2 commented on the implications of low acu-ity or nonurgent ED visits for health care costs but did notdiscuss other reasons for considering these visits as impor-tant to policy. A consultation in an ED could be less suit-able than one provided by a primary care physician if a pa-tient’s condition would benefit from continuity of care or adiscussion of nonclinical factors.Furthermore, nonurgent ED visits use resources, includ-ing time, for which other patients may have a greater clini-cal need. One response to the overuse and misuse of EDsin England has been to design services in which nonemer-gency patients are unable to access the ED unless directedby a primary care physician working in a center co-locatedwith the ED.3 The cost-effectiveness of this form of servicedelivery is yet to be determined, but it is presumed to pre-vent conditions that are treatable in primary care from reach-ing the ED, thereby reducing ED workload.The role of primary care physicians in initiating and di-recting hospital care also has received attention in theUnitedStates.4 Adams2 suggested that reform policies should fo-cus on “ . . . patients who generate the highest costs, suchas those who use the ED most frequently. . . . ” This im-plies that interventions should focus on patients at greatestrisk of visiting an ED.However, Rose5 highlighted the limitations of the high-risk strategy several decades ago; a large number of pa-tients at low risk of visiting an EDmaymake a greater num-ber of ED visits than a small number at high risk.Consequently, a population strategy that attempts to lowerthe mean level of risk for the whole population could havea larger effect on reducing ED visits.The solutions offered by Adams,2 such as improving ac-cess to primary care physicians and the integration of carebetween EDs and other health services, lend themselves wellto the population approach and may reduce both nonur-gent and urgent ED visits.Thomas E. Cowling, MPHAzeem Majeed, MDAuthor Affiliations: Department of Primary Care and Public Health, Imperial Col-lege London, London, England (t.cowling@imperial.ac.uk).Conflict of Interest Disclosures: The authors have completed and submitted theICMJE Form for Disclosure of Potential Conflicts of Interest and none werereported.1. Health and Social Care Information Centre. Accident and emergency atten-dances in England. http://www.hscic.gov.uk/searchcatalogue?q=title%3A%22accident+and+emergency+attendances%22&area=&size=10&sort=Relevance&topics=0%2FHospital+care. Accessed May 10, 2013.2. Adams JG. Emergency department overuse: perceptions and solutions. JAMA.2013;309(11):1173-1174.3. Healthcare for London. A service delivery model for urgent care centres: com-missioning advice for PCTs. http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/Urgent-care-centres-delivery-model.pdf. Accessed May 10, 2013.4. Schuur JD, Venkatesh AK. The growing role of emergency departments in hos-pital admissions. N Engl J Med. 2012;367(5):391-393.5. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14(1):32-38.In Reply: The suggestion of Mr Cowling and Dr Majeed toensure the availability of primary care when and where thepatients need it should be encouraged. As new models toincrease the accessibility of primary care services are devel-oped and evaluated, policy makers must be careful to avoida priori assumptions that EDs are overused andmisused be-cause of poor decisions on the part of patients.The reasons people visit the ED for care are often ratio-nal and understandable, driven by a perceived need for im-mediacy of treatment and lack of an accessible alternative.1Many conditions treatable in primary care that are cared forinside EDs in the United States may reflect problems withLETTERS©2013 American Medical Association. All rights reserved. JAMA, June 26, 2013—Vol 309, No. 24 2549Downloaded From:  by a London Sch of Hygiene & Tropical Medicine User  on 05/12/2018alternative access to rather than inappropriate actions by thepatient.2More than 50% of all acute care visits by the uninsuredare to emergency physicians, who comprise less than 5%of the total number of physicians in the United States.3 Inaddition, for the general population, we must considerthe possibility that EDs are not, in fact, significantly over-used at all.Evidence would suggest that people are not increasinglyreliant on EDs tomeet ambulatory care needs. Between 1999and 2009, total ambulatory visits increased from 841 mil-lion to 1.13 billion, or 3720 visits per 1000 people annu-ally.4 During this same period, the number of ED visits in-creased from approximately 108 million to 124 million,which is a slower rate of growth.4,5In other words, total ambulatory visits increased morequickly than ED visits, implying that patients are findingaccessible ambulatory care, at least if they have insurance.Visits to the ED currently make up a lower proportion oftotal ambulatory visits than the prior decade. The growthof ED visits might not signal a problem at all, but rather thatour health care system is undergoing fundamental change.This change includes a shift away from inpatient use andtoward outpatient care, especially for the increasing num-bers of patients with complex illnesses.4 During the sameperiod, there has been a decline in hospitalizations, whichwould not have been achievablewithout highly effective am-bulatory services, backed up by 24-hour, relatively uncon-strained access tohigh-intensity, high-quality emergency care.As policy makers look to optimize models for healthcare delivery, it should not be presumed that that ED userates, in isolation, are somehow an indicator of quality orcost-effectiveness. Immediate ED access is an importantpart of the portfolio of health care services provided to apopulation.The proposal by Cowling and Majeed to focus on popu-lation health is quite wise. Reducing the cost of health careis most effectively achieved when the need for health careis reduced. In doing so, policy makers should focus less onED use alone and instead focus on whether patients haveaccessible, cost-effective medical services that will achievedesired health outcomes. As coordinated solutions to achievethis end are implemented, the absolute number of ED vis-its may not decrease, although their proportion in relationto overall ambulatory visits may indeed decline further.James G. Adams, MDAuthor Affiliation:Department of EmergencyMedicine, Northwestern UniversityFeinberg School of Medicine, Chicago, Illinois (jadams@nmh.org).1. Gindi RM, Cohen RA, Kirzinger WK. Emergency room use among adults aged18–64: early release of estimates from theNational Health Interview Survey, January–June 2011. http://www.cdc.gov/nchs/nhis/releases.htm. Accessed April 30, 2013.2. Kellermann AL,Weinick RM. Emergency departments, Medicaid costs, and ac-cess to primary care—understanding the link. N Engl J Med. 2012;366(23):2141-2143.3. Pitts SR, Carrier ER, Rich EC, Kellermann AL. Where Americans get acute care:increasingly, it’s not at their doctor’s office. Health Aff (Millwood). 2010;29(9):1620-1629.4. BarnettML, Song Z, Landon BE. Trends in physician referrals in the United States,1999-2009. Arch Intern Med. 2012;172(2):163-170.5. National Center for Health Statistics. NAMCS/NHAMCSmain site. http://www.cdc.gov/nchs/ahcd.htm. Accessed April 30, 2013.RESEARCH LETTERPrevalence and Correlates of Traumatic BrainInjuries Among AdolescentsTo the Editor: Traumatic brain injury (TBI) among adoles-cents has been identified as an important health priority.1,2However, studies of TBI among adolescents in large repre-sentative samples are lacking.1,2 This information is impor-tant to the planning and evaluation of injury prevention ef-forts, particularly because even minor TBI may haveimportant adverse consequences.2We describe the prevalence of TBI, mechanisms of in-jury, and adverse correlates in a large representative sampleof adolescents living in Ontario, Canada.Methods. Data were derived from the Centre for Addic-tion andMental Health’s 2011Ontario student drug use andhealth survey, consisting of anonymous, self-administeredquestionnaires completed in classrooms (62% response rate)by students grades 7-12 (age range: 11-20 years). A com-plete description of the study, including design and discus-sion of the validity of self-reports, potential nonresponse bias,and limitations, is available.3Traumatic brain injury was defined as an acquired headinjury in which the student was unconscious for at least 5minutes or hospitalized overnight.4 Students were asked ifthey ever had such injury in the past 12 months or in theirlifetime (excluding the past 12 months). Students report-ing TBI in the past 12 months were asked about the sourceof the injury. Questions about consumption of alcohol andcannabis use during the last 12 months and usual gradesreceived were also included.All participants provided signed and parental consent. Re-search ethics board approval was provided by the Centre forAddiction and Mental Health, York University, and publicand Catholic school boards throughout Ontario. The sur-veys were administered during a class period by field staff.Analyses were based on a complex sample design with 15strata (regionschool level), 181 primary sampling units(schools), and 8915 students.All analyses used Taylor series linearization available inthe complex samplemodule in SPSS version 20.0 (SPSS Inc).Multinomial logistic regression was performed fitting the 5factors of sex, grade, past-year alcohol use, past-year can-nabis use, and school grades against a 2-tailed P .05.Results. Themean (SD) age of participantswas 15.1 (1.82)years. The estimated lifetime prevalence of TBI was 20.2%(95% CI, 18.1%-22.4%); 5.6% (95% CI, 4.2%-7.5%) re-ported at least 1 TBI in the past 12 months (4.3% of girlsand 6.9% of boys) and 14.6% (95% CI, 13.4%-15.9%) re-LETTERS2550 JAMA, June 26, 2013—Vol 309, No. 24 ©2013 American Medical Association. All rights reserved.Downloaded From:  by a London Sch of Hygiene & Tropical Medicine User  on 05/12/2018

Overuse of emergency departments.

Thomas E. Cowling

Azeem Majeed

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JAMA