Left Without Being Seen

From Medscape (free subscription required):

Approximately 110 million patients visit emergency departments (EDs) in the United States every year, and 0.5% to 8% of these patients leave before they are seen by ED staff. The Centers for Disease Control and Prevention suggest that this could translate into 1.8 million patients entering, but not being seen, in EDs annually. Research suggests that between 1995 and 2002, the rate of people leaving an ED without being seen increased by 65% — largely as a function of prolonged wait times. The average national wait time in an ED before being seen is 56 minutes.

Patients who go to an ED for care and then leave before being seen represent a significant concern, for both the patients and the ED. The objective of this study was to find out why patients leave the ED without being seen, their perception of how long they waited vs the actual time they waited, and factors that could have prevented the patient from leaving before being seen.

At a busy ED (approximately 65,000 yearly patient visits) investigators conducted a prospective, scripted phone survey of all patients who, during a 2-month period, left without being seen. Outcome measures were the number of patients who left, ability to obtain care after leaving, reason for leaving, perceived and actual time waited, if they had a primary physician, if they would return to the same ED for care in the future, and other factors associated with leaving. Of 11,147 total patients that came to the ED, 127 (1.1%) left without being seen. Seventy-two (56.7%) were interviewed by telephone within 8 days. Of those leaving, 84.7% stated they had a primary physician. Mean patient age was 29.9 years, and 44.4% were male. The patient-reported mean length of time waited before leaving was 73.2 minutes, and the actual mean length of time waited before leaving was 70.4 minutes. The reasons for leaving were:

  • The length of the wait (76.7%);
  • The problem resolved (12.3%); and
  • Other reasons (11.0%).

During the week after leaving the ED, 56.3% were able to obtain medial care. Sixty-five percent said they would seek future emergency care at the same ED, 16.3% would not, and 19.7% would possibly return. During the wait, patients wanted information, laboratory tests or x-rays, and analgesics.

Although hospitals might be concerned about the number of patients leaving without being seen because of legal or fiscal reasons, most of these patients reported that they would return for future ED care. It would be of interest to know why these individuals chose to go to the ED in the first place, because most had a physician and were able to obtain care elsewhere after they left the ED. This suggests that at the time of the visits, patients viewed access at the ED to be higher than it would be with their primary care providers.

The investigators suggest that it might be possible to reduce the number of people leaving the ED without being seen through better triage testing, communication, and attention to pain.

Inspector General Opinion: ED On-Call Pay Not Kickback

From Modern Healthcare:

A new advisory opinion from HHS’ inspector general’s office concludes that a hospital’s plan to compensate physicians for on-call coverage for its emergency department is unlikely to be a conduit for kickbacks.

The unnamed hospital that requested the opinion is described as a 400-bed facility that is the only acute-care provider in the county and is having trouble getting physicians to commit to on-call coverage, with “weeks each month when the hospital does not have needed specialists on call.” The proposed arrangement would pay doctors fixed sums—$100 for consultations, $350 for a surgical procedure, and so forth—when their on-call duties require them to treat uninsured patients.The letter signed by Lewis Morris, chief counsel to the inspector general, acknowledges that hospitals are increasingly and legitimately resorting to paying physicians for on-call coverage. “There is a substantial risk that improperly structured payments for on-call coverage could be used to disguise unlawful remuneration,” the letter states, offering as examples amorphous payment structures that compensate “lost opportunity” when there’s no actual loss of income and payments for services for which the physician then bills another payer.

Under the arrangement discussed, however, the hospital would make only fair-market payments for specific services provided to patients with no insurance. The hospital also made a case for having a legitimate need to compensate physicians in order to round out coverage, which the letter concludes would “promote an obvious public benefit” by improving indigent care at the county’s only acute-care hospital.