Emergency department directors measure value in their departments with a number of metrics that are tracked religiously: door-to-provider times, ambulance drop-off times, left without being seen rates, length of stay for discharged patients, diversion hours, and 72-hour returns all come to mind.
These metrics clearly measure the performance of the emergency department, what to they do, if anything, to measure the value of care being provided? These metrics are often presented to hospital administration either monthly or quarterly to demonstrate the performance of the emergency department. Emergency physicians in the ER are now the key gatekeeper for nearly half of all hospital administrations, so it makes sense that the hospital leadership would have an interest in what goes on there.
But what do these metrics mean for the average the patient entering the facility? Certainly they will have an interest in short door-to-provider times and lengths of stay. But do they truly perceive value there? Are they getting a good deal on the care they receive? Clearly there is cost involved in health care and it is quite variable from one hospital to another. So how does the consumer know if they are getting high quality but low cost care? How does the consumer know if they are getting value?
The answer is, they don’t.
Patients know they are sick and need to see someone to determine what’s wrong and get treatment. There is some idea of what will happen, but the care provided in emergency departments is highly variable. There are few if any standards around evaluations and work-ups and little if any understanding of the cost associated with those work-ups.
Take the patient presenting with chest pain. Many emergency departments have the following studies ordered by protocol before the patient is ever seen by a provider: EKG, troponin, d-dimer, BMP, CBC, telemetry and potentially others. There is a cost not just with the test but also with the outcome of the test. An elevated d-dimer will likely result in a chest CT looking for a pulmonary embolus.
The value being provided at this stage is difficult to assess. Few patients are presenting to the ED with an acute myocardial infarction that wasn’t recognized by EMS or upon the patient’s immediate evaluation in the ED. Experienced ED providers have a knack for identifying who is sick and who isn’t with very little information.
Many will say the ED providers order so much costly testing to avoid being sued. I do suspect that’s some of it but I am sure there are many other issues which result in overuse of testing, such as trying to be efficient in getting patients evaluated quicker.
Until those in health care begin to implement standards related to patient evaluations and treatments with a keen understanding of the cost per unit of service, we’ll never get to actual value in health care.
It’s coming, but slowly. Clear guidelines on the use of head CTs in the patient suffering from syncope and recommendations on radiographic imaging for the patient with low back pain are examples. We as physicians will need to take the lead in establishing standards and guidelines. Proper use of expensive testing based on patient evaluation and an understanding of the costs of what is ordered and the potential impact on the patient and the organization are needed. Only then we can truly discuss value in health care delivery.
Robbin Dick is observation medicine services director, Medical Emergency Professionals. He blogs at the The Shift.
