Disease Management Update
Volume IV, No. 41
February 7, 2008

Dear Healthcare Intelligence Network Client,

Non-emergent emergency department (ED) usage can be a huge roadblock in proper disease management. It can drastically increase the cost of disease management and can seriously interfere with caring for truly needy patients in a timely and appropriate manner. Without the benefit of medical homes, many people head to the ED for everything from headaches and backaches to gastritis and lumbago.

This week's Disease Management Update looks at two studies involving ED usage. While one study focuses on a dangerous increase in ED wait times, another notes a drastic increase in visits related to staph infections.

Visit HIN's blog to read about the value of educating patients about appropriate ED use.

Your colleague in the business of healthcare,
Laura M. Greene
Editor, Disease Management Update

If this is a forwarded copy of Disease Management Update and you like what you see, you can register to receive your own copy of this complimentary service. Sign up at:

Table of Contents

  1. Nationwide Increase of ED Wait Times
  2. Disease Management Q&A: The Difference Between Urgent and Emergent Care
  3. HealthSounds Podcast: Implications & Impact of Retail Clinics
  4. ED Visits for Skin Infections Increasing Dramatically
  5. Survey of the Month: Health and Wellness Coaching
  6. Dealing with Unnecessary ED Visits

1. Nationwide Increase of ED Wait Times

Waits for emergency care are getting longer each year, according to a new study from Harvard Medical School researchers, published online by the journal Health Affairs. The study, which analyzed the time between patients' arrivals in the emergency department (ED) and when they were first seen by a doctor, found that the increasing delays affected everyone, including those with and without health insurance, and people from all racial and ethnic groups.

Severely ill patients suffered the largest increases in ED waits. Between 1997 and 2004, waits increased 36 percent for all patients (from 22 minutes to 30 minutes, on average). However, for those whom a triage nurse classified as needing immediate attention, waits increased by 40 percent (from 10 to 14 minutes). Waits increased the most for emergency patients suffering heart attacks, who waited only 8 minutes in 1997, but 20 minutes in 2004, a 150 percent increase. A quarter of heart attack victims in 2004 waited 50 minutes or more before seeing a doctor. While all demographic groups experienced lengthening ED waits, waits were slightly longer for blacks (13.0 percent longer than non-Hispanic whites) and Hispanics (14.5 percent longer). Women also had longer waits (5.6 percent longer than men), while rural hospitals’ patients had the shortest waits. Additionally, ED crowding in the remaining EDs causes one ambulance to be diverted away from a U.S. ED every minute according to the National Center for Health Statistics.

“One contributor to ED crowding,” said Dr. David Himmelstein, associate professor of medicine and senior author of the study, “is Americans’ poor access to primary and preventive care which could address medical issues before they become emergencies.”

To learn more about this study, please visit:

2. Disease Management Q&A: The Difference Between Urgent and Emergent Care

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's experts are Karen Amstutz, M.D., regional vice president and medical director at WellPoint State Sponsored Business, Lakshmi Dhanvanthari, M.D., staff vice president and medical director at WellPoint State Sponsored Business, and James Glauber, M.D., medical director for Neighborhood Health Plan of Massachusetts.

Question:How can a healthcare professional drive home to patients the differences between urgent care and emergent care facilities and when to use each?

Response: (Dr. Karen Amstutz) It really relates back to the health literacy of members. We’re a state-sponsored plan, and the health literacy of our members in general is lower than that of an average commercial plan population. That is one of the challenges that we try to address when we work with our members. In fact, we actually name our ER initiative the “self-care initiative” because one of our strategies is to try to teach patients how to distinguish between conditions they could care for by themselves or conditions that they might want to call our nurse line for versus conditions that they should be more worried about.

(Dr. Lakshmi Dhanvanthari) The same efforts that we use with the members. When physicians and other providers see the members, they should educate them about the difference between an emergent condition versus conditions for which they should be seen in the PCP’s’s office. That would be helpful as well.

(Dr. James Glauber) There are various ways to define this. The first and most important thing is that healthcare professionals — and more specifically PCPs — should strive to create a medical home for their patients. That’s probably the single most important strategy toward reducing inappropriate ER use. When a member or a patient is established in a high quality relationship with a PCP and practice, then they are more likely to seek care and/or advice when they have an urgent medical problem arise.

To that point, I think physicians, their staff or their practice literature can make clear to patients how to seek care or medical advice during times when the practice is not available or open to see patients — specifically in the evenings and on weekends and holidays. To the extent that practices can be quickly available to give people advice on emerging medical problems, that’s an important strategy toward reducing inappropriate use of the ER. Obviously, practices that have expanded hours of operation or adequate coverage arrangements so that they can see patients for urgent medical problems in the evening and weekends will enable their patients to seek care that is timely, appropriate and less expensive than going to the ER.

For more information on reducing non-emergent ED utilization, please visit:

We want to hear from you! Submit your question for Disease Management Q&A to info@hin.com.

3. HealthSounds Podcast: Implications & Impact of Retail Clinics

In this week's Disease Management podcast, Dr. Thomas Atkins, medical director of Sutter Express Care, drugstore-based medical clinics that are part of Sutter Health's network of hospitals and doctors serving northern California, discusses how to establish locations for retail clinics, the sharing of clinic information with PCPs and the impact retail clinics can have on reducing non-emergent ED as well as healthcare costs.

To listen to this complimentary HIN podcast, please visit:

4. ED Visits for Skin Infections Increasing Dramatically

Emergency department (ED) visits for skin infections have increased since a new strain of staph was discovered, according to the Brigham and Women’s Hospital (BWH) and Children’s Hospital Boston report in the February issue of Annals of Emergency Medicine.

The research team assessed data from 1993 through 2005 and found that visits to U.S. EDs for skin infections almost tripled, from 1.2 million in 1993, to 3.4 million in 2005. They also found that when doctors prescribe antibiotics for skin infections, they are likely to use an inexpensive old antibiotic called Bactrim, a sulfa drug. The researchers emphasized that newer antibiotics should be conserved, because the more they are used, the more likely bacteria is to develop resistance to them.

“This is a major public health problem that we need to keep an eye on,” said Daniel J. Pallin, M.D., M.P.H., of the Departments of Emergency Medicine at BWH and Children’s Hospital Boston. “Having said that, the public should not be unduly alarmed by sensational stories. People with skin infections should see their primary care doctors within a day or two. If that’s not possible, emergency departments are available 24/7, and emergency physicians are quite familiar with these infections.”

To see more of this survey's results, please visit:

5. Survey of the Month: Health and Wellness Coaching

Complete our online survey on health and wellness coaching by February 29, and you'll get a free executive summary of the compiled results.

To participate in this survey and receive its results, please visit:

6. Dealing with Unnecessary ED Visits

In an effort to curb non-emergent ED use, hospitals and health plans nationwide are developing strategies to reduce reliance on EDs for non-emergent care. HIN conducted a non-scientific online survey in July 2007 and found out how 220 organizations including hospitals, physician organizations, health plans and more respond to the issue of non-emergent ED use.

To download this complimentary white paper, please visit:
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