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Editor's Comment
Access to Care

A Brief Window to Rethink Emergency Care

  • 1Deputy Editor, JAMA Health Forum
  • 2Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee

A year ago, dramatic declines in emergency department (ED) use, coupled with increases in telehealth visits, would have been greeted as a success. Instead, when the Centers for Disease Control and Prevention reported a 42% decline in visits during the first 6 months of this year, it raised concerns that the drop was due to ill-advised avoidance of EDs out of fear of contracting the novel coronavirus.1,2 Still, some of this decline may have been due to changing needs for care—ie, fewer injuries among those staying home—and some due to people resetting their threshold for visiting an ED, perhaps as a result of being offered the more efficient option of a telehealth visit.3 If the latter is the case, we should be seeking ways to extend and expand upon this pattern.

As of this month, however, some insurers are rolling back coverage of telehealth, and in-person visits rates are recovering. Without access to telehealth, emergency visits could even rebound beyond prior levels owing to the exacerbation of conditions left too long untreated during the public health emergency.4 In short, the window during which to rethink emergency care is closing.

It is worth noting that emergency medicine is a relatively new field—the first residency program in emergency medicine began just 50 years ago—and that emergency medicine is not recognized as a specialty in many medically advanced countries. Instead, anesthesiologists, primary care physicians, and surgeons provide emergency care. In the US, in contrast, we have highly trained emergency medicine doctors, but, ironically, these specialists often spend a large portion of their time practicing poorly coordinated primary care.

Given that emergency medicine originated, in part, out of concern about lack of access for the poor and underserved,5 it is important to retain this objective; however, prepandemic shortcomings of EDs should not be forgotten. Long waits for emergency department care prior to the pandemic and widespread reports of emergency department “frequent fliers” using a disproportionate amount of care point to problems with the model.4 Indeed, a study from the Agency for Healthcare Research and Quality found that “a sizable portion of ED revisits may be driven by factors that cannot be readily addressed from or by EDs themselves.” Other risks are also associated with the current model of emergency care and related care fragmentation, such as elevated mortality upon readmission after emergency general surgery.6

How then can we seize this opportunity to provide better access to primary and urgent care, in addition to specialized services for people with truly emergent care needs? First, we can learn how to use—and reimburse7—telehealth services appropriately throughout the pandemic and beyond. Second, we can encourage services that provide non-ED care options for families and that can complement telehealth services. Urgent care centers, for example, might provide in-person assessments and tests to follow up on recommendations made during telehealth visits. This would mean people would not need to resort to an ED and could maintain continuity of care with their primary care provider. Urgent care use has been found to provide better access to care for some population segments but needs to be more widely available.8 Third, we need overarching systems to triage patients to the appropriate care modality and to ensure that their data and care history follow them. Each of these strategies could free up time and capacity for emergent care in our overburdened EDs.

Finally, we should develop better strategies for rapid emergency care response for future pandemics and natural disasters. This pandemic has shown that health care professionals can mobilize and train up quickly to confront a new threat. Emergency medicine specialists should drive this response strategy; while they do, they should not be tasked with simultaneously filling in the persistent gaps in our routine health care systems.

References
1.
Hartnett  KP, Kite-Powell  A, DeVies  J,  et al.  Impact of the COVID-19 pandemic on emergency department visits—United States, January 1, 2019–May 30, 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(23):699–704. doi:10.15585/mmwr.mm6923e1Google Scholar
2.
Wessler  BS, Kent  DM, Konstam  MA.  Fear of coronavirus disease 2019-an emerging cardiac risk.   JAMA Cardiol. 2020;5(9):981-982. doi:10.1001/jamacardio.2020.2890Google ScholarCrossref
3.
Kocher  KE, Macy  ML.  Emergency department patients in the early months of the coronavirus disease 2019 (COVID-19) pandemic—what have we learned?   JAMA Health Forum. Published online June 9, 2020 doi:10.1001/jamahealthforum.2020.0705Google Scholar
4.
Woodruff  A, Frakt  AB.  COVID-19 pandemic leads to decrease in emergency department wait times.   JAMA Health Forum. Published online September 17, 2020. doi:10.1001/jamahealthforum.2020.1172Google Scholar
5.
Zink  BJ.  History of medicine: social justice, egalitarianism, and the history of emergency medicine.   Virtual Mentor. 2010;12(6):492-494. doi:10.1001/virtualmentor.2010.12.6.mhst1-1006Google Scholar
6.
McCrum  ML, Cannon  AR, Allen  CM, Presson  AP, Huang  LC, Brooke  BS.  Contributors to increased mortality associated with care fragmentation after emergency general surgery.   JAMA Surg. 2020;155(9):841-848. doi:10.1001/jamasurg.2020.2348Google ScholarCrossref
7.
Berenson  R, Shartzer  A.  The mismatch of telehealth and fee-for-service payment.   JAMA Health Forum. Published online October 2, 2020. doi:10.1001/jamahealthforum.2020.1183Google Scholar
8.
Burns  RR, Alpern  ER, Rodean  J,  et al.  Factors associated with urgent care reliance and outpatient health care use among children enrolled in Medicaid.   JAMA Netw Open. 2020;3(5):e204185. doi:10.1001/jamanetworkopen.2020.4185Google Scholar
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