Emergency Room Utilization in the First 15 Months of Life: A Randomized Study

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486 PEDIATRICS Vol. 63 No. 3 March 1979

Emergency

Room

Utilization

in the First

15 Months

of

Life: A Randomized

Study

Nigel Paneth, M.D., M.P.H., Deborah Bell, and Ruth E. K. Stein, M.D.

From the Department of Pediatrics, Pediatric Ambulatory Care Dicisiot,, Allwrt Linst(’i7 College of ,h’(lici1ae of Yes/afro ( Tniuersity, and Bronx Municipal Hospital C’enter, Bronx, New )ork

ABSTRACT. The impact of a systeni of primary pediatric care on emergency room use in a municipal hospital was measured by comparing that use in two randomly selected populations. The population that was offered participation

ill a primary care program consistently used the emergency room less than did the control group. Analysis of the pattern of utilization revealed that the differences were limited to patients who actually participated in the program, and to weekday use of the emergency room. Unusually heavy

(

greater than ten visits per year) use of the emergency room was virtually eliminated among participants in the primary care program. Pediatrics 63:486-490, 1979, ambulatory care, (lelicery of health care, hospital emergency sercices, nurse

practitioners, priniary health ‘are.

A major change in the delivery of ambulatory health care in the United States in recent decades has been the large increase in patient use of the emergency room. ‘.2 Part of this increase has been

the substitution of the emergency room for

primary care, particularly in inner cities.36 This

has led to attempts to measure the effect of

comprehensive primary care programs on the use

of emergency services by inner-city populations.

Results of these evaluations have been inconclu-sive, with some centers noting decreases in emer-gency room use,7 others experiencing no change8 or even increases.” All such studies have

attempted to measure the impact of

comprehen-sive care by sampling emergency room records of geographically defined patient populations

(

usually by census tracts) before and after the

introduction of comprehensive care. They have

had to contend with the fact that not all census tract residents are participants in the

comprehen-sive care program, and that other changes

affect-ing utilization may be occurring simultaneously. These reports assume that patients in areas served

by comprehensive care centers are comparable in

their use of emergency services to patients in

other census tracts. For these reasons, we

under-took to measure the impact of a system of

pediatric primary care on emergency room use by

comparing the experience of two randomly

selected populations, only one of which was

offered participation in the primary care

program.

MATERIALS AND METHODS

Bronx Municipal Hospital Center is an 850-bed

general hospital in the east-central Bronx and is a

major teaching affiliate of the Albert Einstein

College of Medicine. General pediatric

ambulato-ry services include an emergency room that provides 85,000 annual visits, a general pediatric

clinic with about 20,000 visits per year, and a

pediatric nurse practitioner program providing about

5,000

visits annually. The population served is predominantly black and Hispanic, with

a substantial minority of ethnic European

patients.

The general pediatric clinic is staffed by house

officers under attending physician supervision.

All patients are assigned to specific house officers

to provide continuity of care. Although patients are encouraged to contact their physicians when

they need to, walk-in and call-in services are not

formally available in the clinic, and unscheduled

Received June 2; revision accepted for publication Decem-ber 18, 1978.

Read in part before the annual meeting of the Ambulatory Pediatric Association, San Francisco, April 25, 1977. ADDRESS FOR REPRINTS: (R.E.K.S.) Department of Pedi-atrics, Bronx Municipal Hospital Center, Peiham Parkway and Eastchester Road, Bronx, NY 10461.

at Viet Nam:AAP Sponsored on September 7, 2020 www.aappublications.org/news

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ARTICLES 487

I

ALL WELL BMHC NEWBORNS WITH LESS THAN 3 SIBLINGS

(n=200)

Experiment Control

*For one patient infcrnation on clinic use ‘as not availaHe

Distribution of the study population among health care alternatives.

medical problems are cared for in the emergency room.

The pediatric nurse practitioner program offers

comprehensive pediatric care, with the

practi-tioners functioning as primary providers, using

attending pediatricians for back-up. Walk-in and call-in services are available on weekdays from 9

AM to 5 PM. At other times, unscheduled medical

problems are managed in the emergency room.

A randomization process is used in assigning

patients to the pediatric nurse practitioner

program. Healthy newborns with less than three siblings are randomized, using a random number table, to be either offered or not offered partici-pation in the program. Thus a control group is

continually being generated that consists of

newborns not offered participation in the program whose pediatric care is obtained at the

Bronx Municipal Hospital Center general

pediat-nc clinic, primary care health stations, or

else-where.

This randomization process provided a mecha-nism for testing the hypothesis that one particular

primary care scheme, our pediatric nurse

practi-tioner program, could reduce emergency room

utilization.

A cohort of 200 healthy newborns born

between July and October 1975, who had been so

randomized, were selected for study. The hospital

charts of all of the study infants were reviewed,

and the total number of emergency room visits

noted in the chart was recorded, as were the time

of day and the day of the week of each visit. As all

charts were not reviewed at the same time, the

period of time under review differed somewhat for each patient. The length of time of the period

under review averaged 15 months in this study

and is not different for experimental or control groups, nor for any of the subgroups to be

compared.

The Figure illustrates the distribution of the

200 study patients among various health care

alternatives. One hundred families constituted

the experimental group that was offered

partici-pation in the pediatric nurse practitioner

program; 55 accepted and 45 refused. The most common reasons for refusal were distance from the hospital and prior enrollment of other siblings in another source of care, including, in some

instances, the general pediatric clinic at the Bronx Municipal Hospital Center. Of the 45 refusers, 16 became users of our general pediatric clinic, and

28 were nonusers of the clinic. A nonuser is here

defined as a patient who has never attended the

general pediatric clinic. For one patient,

informa-tion on clinic use was not available. Among the

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488 EMERGENCY ROOM UTILIZATION

TABLE I

COMPARABILITY OF EXPERIMENTAL AND CONTROL GROUPS

Experimental Control

Mean maternal parity 1.72 1.85

Percentage with Hispanic 56 47

Surname Family residence

South Bronx 9 9

(zip codes 10451-10455)

Central Bronx 24 26

(zip codes 10456-10460)

East Bronx 10 11

(zip codes 10461-10465)

North Bronx 26 28

(zip codes 10466-10469)

South East Bronx 31 26

(zip codes 10472-10475)

100 control families (those not offered participa-tion in the nurse practitioner program) 60 became clinic users and 40 were classified as nonusers.

The experimental and control groups were

comparable in terms of mean parity and proxim-ity of residence to the hospital, two variables

likely to be determinants of emergency room use

(Table I). There was a small, statistically

insignif-icant excess of patients with Hispanic surnames in the experimental group.

RESULTS

Table II shows the mean number of emergency room visits by patients in the experimental and control groups during the study period. The visits are divided into weekday visits (8 to 5 PM,

Monday through Friday) and off-hour visits (all

other times). The control group averaged 3.64

total visits in the study period, the experimental

group 2.61. The probability of this 28% reduction in utilization occurring by chance is .074.

Patients who used the general pediatric clinic visited the emergency room an average of more

than five times during the study period. Infants

who had never been seen at the Bronx Municipal

Hospital Center for primary care visited the

emergency room only a little more than once on

average. These patterns of behavior were almost

olt appears that the pediatric nurse practitioner program took most of its patients from families who would otherwise have used the pediatric ctinic, but it may have converted

some nonusers of our facility to users, as the total of Bronx

Municipal Hospital Center users in the experimental group

was 71 and in the control group 60.

identical for these subgroups in both

experimen-tal and control groups. The pediatric nurse prac-titioner patients had a pattern of use of the

emergency room intermediate between nonusers

of our facility and our clinic patients, averaging

2.42 visits in the study period. This figure

repre-sents 54% less use of the emergency room by

pediatric nurse practitioner patients than by clinic patients, a difference significant at the .001

level. It is clear that the only source of variance between the total experimental and control

groups was the behavior of the pediatric nurse

practitioner patients.

A breakdown of emergency visits by time of

day and day of occurrence reveals that the

differences in utilization were essentially limited to periods when the nurse practitioner program was open and access was available. The experi-mental group used the emergency room during

the day only half as often as the control group, a difference significant at a level of less than .005.

During weekdays, nurse practitioner patients

used the emergency room 76% less than clinic patients (P < .001).

No significant differences were found between

experimental and control groups, nor between

nurse practitioner patients and other clinic

patients, for emergency room visits on nights and

weekends.

In addition to analyzing the mean number of

visits in each group, we were able to look at the

distribution of unusually heavy users of the

emer-gency room among the different patient

subgroups (Table III). It was decided a priori that ten or more emergency room visits during the

study period probably represented inappropriate

use of the emergency room. Table III presents a breakdown of the patient population by number of emergency room visits. There were no heavy

users of the emergency room among either the 55

pediatric nurse practitioner patients or the 68 nonusers of our primary care facilities, but 17 of

the 76 clinic patients had been seen in the

emergency room on ten or more occasions.

DISCUSSION

Randomization prior to offering the program to patients did not allow us to test our hypothesis in the most direct way, since not all members of the experimental group were users of the program under study. Despite this methodological

difficul-ty, it is clear in Table II that the only source of

differences between the experimental and control groups is the different behavior of patients enrolled in the pediatric nurse practitioner

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ARTICLES 489 TABLE II

MEAN NUMBER OF EMERGENCY ROOM VISITS PER PATIENT IN STUDY PERIOD

Experimental Control

Weekday (.)ff-Iiour Total Weekday Off-hour Total

Pediatric-nurse- 0.53 1.71 2.42 . .. . . . ..

l)ractitioller

1)atiet5

Clinic users 2.31 2.81 5.56 2.18 2.22 5.22

Noncli,iic users 0.39 0.89 1.36 0.475 0.70 1.28

Total 0.77#{176} 1.65 2.61t 1.500 1.61 3.64t

OP < .005 (two-tailed Students’ (-test).

1?

= .074 (two-tailed Students’ t-test).

program. This is impressive evidence for the

hypothesis that a primary care program can

reduce dependence on the emergency room.

Despite a 45% refusal rate of the program, the

experimental group’s use of the emergency room

was still markedly different from that of the

control group. Furthermore, the similarity of

behavior of clinic patients and nonfacility users in

both experimental and control groups, and the

comparability of the two groups as shown in

Table I, attest to the success of the randomization

process in equally distributing patient character-istics.

An important finding in our study is that the

differences in emergency room use paralleled the

availability of the primary care program. The major difference in use between experimental and control groups occurred at times when patients

had access to the primary care program. This

finding suggests that lack of access to the provider

is a major reason for emergency room use in an

area such as ours. This phenomenon has also been

suggested as an explanation for emergency room

use during evenings and weekends in some subur-ban areas where physicians are less accessible at

these hours.’

It is possible that differences in the nature of

the interaction between nurse practitioners and

parents, as compared with that of house officers

and parents, may account in part for the results of

our study. The relationship between parent and

practitioner is probably more strongly cemented

than that between parent and physician in our

clinic setting. The pediatric nurse practitioner program incorporates a postpartum home visit,

and parents and practitioners first meet while

mothers are still hospitalized after delivery.

Neither of these features is routinely operative in the clinic setting. In addition, the high rate of

utilization of the emergency room by clinic patients in this sample undoubtedly reflects the

relative unavailability of full-time primary care coverage in our general pediatric clinic.

The economic impact of decreasing emergency room use was not analyzed in this study. Since the decrease in emergency room utilization was accomplished in large measure by having primary

care visits replace emergency room visits, the

financial savings would be expected to be

predominantly in the area of reduced laboratory and radiologic investigations and appointments

for repeat examination compared with

emergen-cy room care.”

The marked reduction in the prevalence of

patients who use the emergency room frequently suggests that such behavior is modifiable given

access to primary care. This study reinforces the

concept that excessive emergency room

utiliza-tion in inner cities relates directly to the absence

of primary care and not to a fixed behavior

pattern of inner-city residents.

TABLE III

NUMBER OF PATIENTS IN EACH SUBGROUP SEEN IN THE EMERGENCY ROOM TEN TIMES OR MORE DURING THE

STUDY PERIOD

Experiniental Control

Pediatric nurse practitioner patients Clinic users Nonctinic users Total 0/55#{176} 4/16 0/28 4/lOOt 13/60#{176} 0/40 13/lOOt

#{176}P< .005 (Fisher’s exact test).

tx 3.014; P < .09; df 1.

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490 EMERGENCY ROOM UTILIZAT1ON

REFERENCES

1. Kunian L: Rote of the emergency unit in a community hospital. N Engl I Med 283: 1367, 1970.

2. Shortliffe EC, Hamilton TS, Noroian EH: The emergen-cy room and the changing pattern of medical care. N Engl I Med 258:20, 1958.

3. Starfield B: Letter: Proper use of emergency facilities. N

Engl I Med 292: 1 188, 1975.

4. Torrens PR, Yedvab DG: Variations among emergency room populations: A comparison of four hospitals in New York City. Med Care 8:60, 1970.

5. Roth JA: Utilization of the hospital emergency depart-ment. I Health Soc Behav 12:312, 1971.

6. Atterbury CE, Weil TP, Donnell HD: Factors affecting emergency room tilization. South Med I 61:1061, 1968.

7. Hochheiser LI, Woodward K, Charney E: Effect of the neighborhood health center on the use of pediatric

emergency departments in Rochester, New York. N Engl I Med 285:148, 1971.

8. Moore GT, Bernstein R, Bonanno RA: Effect of a neighborhood health center on hospital emergency room use. Med Care 10:240, 1972.

9. Roghmann KG, Goldberg HJV: The effort of the Roches-ter neighborhood health center on hospital dental emergencies. Med Care 12:251, 1974.

10. Ketman HR, Lane DS: Use of the hospital emergency room in relation to use of private physicians. Am I Public Health 66:891, 1976.

11. Heagarty MG, Robertson LS, Kosa J, et at: Some comparative cost in comprehensive versus

fragmen-tary pediatric care. Pediatrics 46:596, 1970.

THE RISE OF PROFESSIONALISM

Professional work conditions (and not only the general ideology) foster

individualism. The professional’s sense of power and authority flows not only from his actual command over special knowledge but also from his control over

interpersonal situations. The first established professions-medicine, law, the ministry, and architecture-were typically concerned with the problems of

individuals. Only indirectly did they define society as their client. Today, individualized service becomes an ideological remedy for the ills of a social situation, a screen for the social problems caused by the bureaucratic systems

through which services are delivered-most notably in the medical and

teaching professions.

The ideological insistence on individual aspects, the neglect of the whole,

merges with specialization to confine the professional in an ideological

conception of his role: the importance of narrow responsibilities is consciously

and unconsciously emphasized, exaggerating the “dignity” of the functions. The dominant ideology attributes to professionals and experts special prestige as well as “moral and intellectual superiority”: sharing in this ideology, professionals can easily mystify to themselves their actual power. Moreover,

they are locked into conformity with the role society offers them to

play-locked in by their vocational choice, by the particular mystique of each

profession, and by their whole sense of social identity.

Finally, the technocratic ideology of science and objectivity excludes from

the specialist’s concern the social and political consequences of his acts.

Nowhere is this truer than in the technical and scientific fields. M. L. LARSON

Submitted by Student

From Larson ML: The Rise of Professionali.s-;n: A Sociological Analysis. Berkeley,

University of California Press, 1978.

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1979;63;486

Pediatrics

Nigel Paneth, Deborah Bell and Ruth E.K. Stein