Emergency department use by family practice patients in an academic health center

Background and Objectives: With the proliferation of managed care, efforts are being made to reduce emergency department (ED) use after hours and eliminate unnecessary ambulatory visits during office hours. This study characterized the after-hours ED use by a family practice residency patient population and determined differences in appropriate ED use by patients calling ahead versus those arriving at the ED without calling first. American College of Emergency Physicians guidelines were used to define appropriateness of visit. Methods: A retrospective ED chart and on-call log review were used to obtain data. Results: A random sampling of family practice patients from January 1993 to December 1994 (n=332) showed that, overall, 62% of patients did not call prior to their ED visit. Calling ahead was not associated with more appropriate ED use. Of those who called ahead, 63% had an appropriate ED visit, compared with 61% of those who did not call ahead. Men were more likely to appropriately use the ED than women. Patients age >64 were more likely to have appropriate ED visits than other age groups. Conclusions: We found no relationship between calling ahead and appropriate ED use. Possible explanations include that resident physicians are inexperienced and may be uncomfortable with telephone triage due to a lack of formal telephone management training. Patients may misrepresent the severity of their illness. Further, a patient who wants to be seen after hours must be seen for medical legal reasons. Interestingly, privately insured or Medicare recipients were more likely to use the ED appropriately. This association may suggest that fiscal accountability contributes to appropriate utilization, a scenario likely to change as managed care organizes Medicaid and indigent patients.