Overuse of emergency room reducible through primary care relationship

April 17, 2020

LAWRENCE, KANSAS -- David Slusky keeps hearing the same comments from other parents who are isolating with young children.

"They're telling their kids, 'Please don't do gymnastics on the stairs because this is not the week I want to take you to the hospital!' Many of us are trying to both avoid getting COVID-19 and anything that might send us to the hospital," said Slusky, associate professor of economics at the University of Kansas.

He believes Americans have now been reminded how dangerous this situation is ... even without a pandemic exacerbating matters.

"Because errors can happen or infections or complications, you don't want to be in a hospital unless you really need to be in one," he said. "I'm not recommending people set up ICUs in their garage. But if you have a condition where you can see a primary care provider and not go to the ER, that's ideal."

That's also the contention of his latest paper, "Office Visits Preventing Emergency Room Visits: Evidence from the Flint Water Switch," distributed by the Institute of Labor Economics.

Co-written with Shooshan Danagoulian and Daniel Grossman, the research looks at the infamous case of Flint, Michigan. In 2015, the city issued an advisory alerting residents to increased lead in drinking water after its water source was switched from Lake Huron to the Flint River. The result was thousands of children exposed to potentially toxic levels of lead, along with exposing a governmental conspiracy that led to 15 criminal indictments.

Slusky's analysis suggests that children were more likely to receive care from the same clinic following lead tests. Establishing such care reduced the likelihood parents would take them to emergency rooms for conditions treatable in an office setting.

"This is not only a paper about Flint," Slusky said.

"This is also a paper about overuse of the emergency room, and specifically overuse of the emergency room in a low-income population. These people are often the least medically connected, with the least time and least education to manage these kinds of complex problems."

His team used an algorithm created by New York University physicians that takes hospital discharges and categorizes them broadly into four categories: unpreventable emergencies, preventable emergencies, conditions requiring office visits and conditions that will resolve themselves.

"We use that to think about the number of avoidable visits happening in this diagnosis," he said.

In Flint, building a relationship with a primary care physician proved vital to the decision of whether parents would take their children to the ER for something that might be noncritical (such as high fever or diarrhea).

He said, "In a town where the emergency manager and governor misled you, the only person who took you seriously that your kid might be sick was your physician. So maybe you'll go to the doctor more now."

The connection between primary care and emergency care -- especially for those with low incomes -- is particularly relevant to the current pandemic.

"Ideally, we don't want individuals who don't need to be there in the emergency room, especially to keep them from infecting others or getting infected themselves. As we increase testing capacity and try to test more of the population and get them back to work, an established and stronger relationship with a primary care provider is crucial," he said.

A KU faculty member since 2015, Slusky specializes in the economics of infrastructure, environment and insurance. Much of his research has addressed the dilemma of lowering health care spending while raising health.

"Right now we're not getting great stuff and we're spending a lot. Giving people health insurance doesn't actually save money, though it is a very good way to get them healthy. So part of this is changing what we care about. And part of it is giving people a broader menu of options, so you can call a nurse at two o'clock in the morning instead of just heading to the ER."

Ultimately, Slusky believes the Flint study can help the health care industry examine a variety of different policies so that parents can determine the best way - both medically and financially -- to help their sick children.

"We need to save our emergency resources for when we actually need them," he said. "And we need to ensure people are aware of and comfortable with other options so they only use emergency resources when needed."

University of Kansas

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