Far from being healthcare’s biggest problem, emergency medicine is a bastion of dependable, efficient care.  

The CDC reports that 123.8 million patients visited an emergency department last year. That’s 41.4 visits per 100 population. That number has risen every year despite numerous, concerted efforts by the government and the insurance industry to stem the rising tide. Could it be that patients see what the politicians and planners seem to be missing, that the model of emergency care by qualified specialists, when and only when you need it, is a good model for health care delivery? It’s not the end all by any means. Chronic care will always have a place. And there are numerous ways that emergency care can be streamlined, improved, and made more cost efficient. But rather than seeing emergency departments as a sign of the problem of declining health care quality and rising health care costs, EDs should be seen as an integral part of the solution.

There is no doubt, that if you have listened to any debate over health care reform over the last several years, you have heard emergency rooms demonized repeatedly as the best example of the excessive costs of our current health care delivery system. “Preventive care” is the mantra that is touted to save our country from financial ruin. While it goes without saying that keeping people from needing a doctor is better for them and cheaper for the system than treating them after they get sick, there are basic assumptions to the preventive care vs. emergency care debate that deserve a closer look.

The first assumption is that preventive care will save money. It makes intuitive sense that healthy people don’t consume health care resources. Therefore, preventive care must save money. Right? Well, not really. Preventive care doesn’t “prevent” illness and death. It only delays it. It is well known that the vast majority of resources consumed on health care over the course of a lifetime, some estimate up to 60%, will be utilized in the final 1-2 years of life when one is battling for every last moment. But this is true whether it occurs after 60 years or 90 years. It is assumed as people get older and more expectant to die, they will go “more willingly,” and spend less health resources, than if they had died younger. In fact, Dr. Kathleen Unroe of Duke University School of Medicine found in her study of 230,000 Medicare patients who died of heart failure between 2000 and 2007 that more patients did choose to utilize hospice. Rates of utilization jumped from 19 to nearly 40 per cent. Although their enrollment was shorter and the rates of hospitalization remained steady, ICU utilization rose. Costs for the last six months of life rose from $28,000 per patient to $36,000.

While it is true that better care for conditions such as COPD, asthma, and other chronic conditions will help prevent unnecessary hospitalization, most of the real benefit of preventative care is from lifestyle changes such as weight loss, proper diet, exercise, and smoking cessation. Even though physicians may threaten, cajole, or educate patients about their lifestyles, we have to admit that we have only modest impact without buy-in from our patients. The cry for less twinkies and more exercise often falls on deaf ears.

Another questionable assumption about the benefit of preventative care is that any disease caught earlier in its course will result in better health for the patient and less cost, both the patient individually and to the system at large. But, is this true? As in most cases, the answer is, “It depends.”

For example, take screening mammography. “Mammography Saves Lives...and one of them may be yours” is a trademarked motto of the American College of Radiology, the American Society of Breast Disease, and the Society of Breast Imaging. Again, it makes intuitive sense that if breast cancer is caught early it will give patients longer, healthier lives, which will ultimately cost less than the protracted treatment of advanced stage disease. But, this may not be the whole story. When asked by Zosia Chestecka of Medscape Today, H. Gilbert Welch MD, MPH, of Dartmouth Institute for Health Policy and Clinical Practice at the Dartmouth Medical School had an alternative motto. “Mammography could save your life,” he said, “but it’s a long shot.” Consider the alternative motto “Chances are it won’t, but mammography could save your life.” Dr. Welch opined in the New England Journal of Medicine that the decision to undergo routine breast screening is, in fact, “a close call.” Why? Nine out of ten times the lesions found are not cancerous and would have required no surgery or radiation if ignored. John D. Keen, MD, MBA wrote, in the Journal of the American Board of Family Medicine, that “the premise of a near universal life-saving benefit from finding presymptomatic breast cancer through mammography is false.” There is a 5% chance that a mammogram will save a woman’s life, but women 40-50 years old are 10 times more likely to experience over-diagnosis and overtreatment than to have their lives saved. Dr. Rita Redberg, Professor of Medicine at the University of California, San Francisco and Editor of the Archives of Internal Medicine made it clear when she told Sharon Begley of the Daily Beast that she (Dr. Redberg) had no intention of getting a screening mammogram even though her 50th birthday had come and gone. So, why are millions of American women spending hundreds of millions of dollars to do so?

Cardiology represents another example benefits of acute care over the questionable benefits of preventative care. There is no doubt whatsoever that prompt diagnosis of acute coronary syndrome (ACS) and prompt intervention by cardiac catheterization and angioplasty saves lives and helps people live longer, healthier lives. But what about preventative cardiac care?

When the 3-D CT scanner was introduced almost a decade ago, Time magazine’s cover claimed that the technology could “Stop a Heart Attack Before It Happens”. The idea, of course, was that patients with mild chest pain, if scanned and found to have vascular plaques, could undergo cardiac catheterization with stenting or bypass surgery, thereby preventing the potential heart attack or at least improving the patient’s quality of life. Neither of these turned out to be true. Study after study has shown that patients with mild chest pain have no improvement in mortality or quality of life over less invasive, and less expensive alternatives, such as beta blockers, cholesterol lowering statins, aspirin, a healthy diet and regular exercise. And the cost of all these unnecessary procedures, around 500,000 costing $50,000 each, makes the cost of visiting the ER look like chump change.
Emergency physicians, contrary to many of our non-EP colleagues, are loathe to do anything that is not absolutely necessary. EPs already have the age old axiom “If it ain’t broke, don’t ‘fix’ it” burned into their brains. This is not to say that there isn’t a place for care for chronic conditions or that everyone should go to the ER for everything, but instead of trying to restrict or discourage patients from going to the ED, maybe they should be encouraged to go there first. Politicians and health policy planners are always talking about “lining up the incentives in the right direction.” That is to say that everyone wins when the patient is given the best possible treatment in the most cost effective and timely manner. Emergency physicians have been doing this for years. Since EPs have no financial interest in whether a patient stays in our practice, which is a nice way of saying that we don’t care if they come to the ER or not, EPs are free to tell the patient what they need medically and, more importantly, what they don’t need. From a time/cost efficiency stand point, who else can order and interpret a lab test or x-ray on the spot. Who is the best person to determine whether a patient needs a costly admission to the hospital or can reasonable be sent home? The answer is the physician who has the least to monetarily benefit, the EP.
Dr. Mark Plaster is the founder and executive editor of Emergency Physicians Monthly




# Not so great at cost-savingUniversity Radiologist 2011-10-25 09:05
Unfortunately, the pressures on ED physicians to turn patients around at a rapid speed lead to astonishing rates of ordering unnecessary and expensive tests. Therefore, I can't agree that the ED is a good place to center patient care.
# MDJames Sullivan 2011-10-26 11:25
I would be curious to know the data source for University Radiologist's comment that EM physicians order "astonishing numbers of unnecessary and expensive tests".
# Unnecessary and expensive testsFrank Loyd 2011-11-01 18:17
I am interested in the data source as well. I tend to avoid big work-ups on anybody that I can. If someone needs it, by all means they get the full court press, but not every patient with a cough needs an x-ray. Many of the physicians I work with do not hold this view - I see a lot of providers that order a CT for every belly pain that walks through the door. The pendulum swings both ways, so I guess as in the answer to almost every question in medicine "it depends", in this case on who is in the ED that particular day.

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