Studying the Link Between Early Primary Care Use and Emergency Room Visits
A recent study produced surprising findings on the effect that early primary care linkage has in relation to emergency department (ED) use. The study by Uma Kotagal, MBBS, MSc, et al, examined healthy infants in an Ohio Medicaid population and aimed to look at the implications of establishing a stable relationship with a primary care physician. The researchers hypothesized that an early link with a primary care provider would be associated with decreased visits to the ED.
Contrary to expectations, Dr. Kotagal found that being exposed to early primary care did not result in fewer visits to the ED. In fact, she determined that mothers of infants taken to the emergency room within the first three months of birth were more likely to have taken advantage of both prenatal care and early primary care.
"The most significant finding is that early primary care, the way it is currently provided for this population, doesn't impact ED use," says Dr. Kotagal, director of Health Policy and Clinical Effectiveness at Cincinnati Children's. "It is interesting to me that the patients who went to the ED were more likely to have had early primary care." This leads her to believe that simply offering primary care is not enough. Rather, the needs of patients and families in this population need to be understood in conjunction with the provision of primary care services.
Collaboration with Wendy Pomerantz, MD, and Charles Schubert, MD, in the Division of Emergency Medicine at Cincinnati Children's provided important input for this study from the ED's perspective. A review of all visits to urgent care based on diagnosis and symptoms found that emergency visits for primary care purposes aren't solely related to convenience. This outcome gives credence to the idea that individuals have different points of view regarding when and how to use emergency care.
Understanding the Findings
This study shows the need for understanding how to meet the needs of patients and families in the health care delivery system.It is critical that primary care providers examine how to offer more access to patients by looking at what customers want and meeting that demand.
"We need to start asking different questions such as, 'do we meet the needs of our patients?' and 'is there a better way to provide primary care?'" Dr. Kotagal says. "We need to understand the population and what their needs are, and help them understand their different options."
Ways to provide services that are driven by the needs of the patients include offering open access to primary care, decreasing wait times and implementing process improvements. Focus groups can be used to further explore what patients want in health care and their personal health beliefs. Taking these steps can pave the path for making primary care more useful for patients and families.
Dr. Kotagal feels the data she and the other investigators compiled was a strong factor in the success of the study. The use of linked data sets from state and national levels allows a better understanding of trends in care. In this study, a linked data set combined birth certificate data which contained characteristics of both infant and mother, to Medicaid claims which described how health care was used.
Applying the Results
Throughout Cincinnati Children's, steps are being taken to address the questions raised in this study. In the Pediatric Primary Care Center, physicians are examining ways they can be more effective in primary care. Lisa Mills, PhD, in the Division of Psychology, has completed a study that looked at health beliefs that make young African American mothers use the ED as a source of care. And in an ongoing Pursuing Perfection initiative at the medical center, teams throughout the hospital are seeking ways they can improve their services and help people become more effective users of the health care system.
Dr. Kotagal is pleased with these efforts to improve delivery of care, and she continues to strive to make improvements within the health care delivery system. She emphasizes that measuring and improving the quality of patient services should be done based on the customers' perceptions. "What is effective is defined by the patient, not by the provider," Dr. Kotagal says. "The most important part is 'ask your patient.'"
Dr. Kotagal's study was published in the Archives of Pediatrics & Adolescent Medicine (156[7]:710-716, 2002 July) and was supported in part by a grant from the Ohio Department of Human Services Bureau of Medicaid Policy.
