My wife who is eight months pregnant went to a routine prenatal appointment last week. She told the OB doctor that she was concerned she had pink eye. OB providers, along with pediatrics, family medicine, and internal medicine all constitute primary care providers (PCP) and pink eye is a common primary care condition.
Surprisingly, the OB physician referred her to the nearest acute care facility. Attributing this provider’s recommendation as rare would be misleading as it is reflective of what acute care facilities (i.e. urgent care, emergency departments) increasingly recognize as a reason for patient referral.
Health policy experts have long predicted that emergency department (ED) utilization would decrease by increasing the availability of primary care and was a theory grounded in how the Affordable Care Act (ACA) was designed. A recent article in the New England Journal of Medicine, however, echoes a common theme that has emerged since the ACA was implemented: ED visits have increased. The authors postulated that increased use of primary care through the ACA could actually be driving greater use of emergency care and quoted one participant as saying “I went to the doctor’s office one time and they said, no, you need to go to the ER because your blood sugar is way too high. It’s going to take us hours to get it down. So you need to go to the ER.”
While self-referrals still constitutes the largest proportion of arrivals in the ED, PCP referrals are an important reason for referral that should be further discussed and investigated. In 2005, RAND released a report that highlighted PCP referrals as an important contributor of ED “traffic.” The Centers for Disease Control and Prevention’s National Center for Health Statistics published data in 2012, noting that 20 percent of patients being discharged from the ED were referred by their PCP. Patients discharged from the ED have often been used by health policy experts as surrogates for patients that could have been managed effectively in outpatient settings. A separate report determined that 23 percent of patients arriving in their ED were referred by their PCP.
Reasons for referral to the ED by providers could be a lack of time, lack of knowledge, lack of resources, lack of staffing, medical-legal, planned admissions, patient preference, as well as others. In my wife’s case, it is hard to understand why the OB did not clinically manage the pink eye and provide their expertise as to the safety of treatment during pregnancy. In other cases, however, one could image a variety of reasons why referral is appropriate. ED utilization is more nuanced than simply being coined, as it so often is, self-referral, costly, and inappropriate. Physician referrals may be the missing link in understanding what continues to drive people to the ED.
Joshua Elder is an emergency physician and Robert Wood Johnson Foundation Clinical Scholar, Yale University, New Haven, CT. He can be reached on Twitter @joshuawelder. Ashley N. Elder is a cardiac intensive care unit nurse.
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