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      In the article titled “Potentially Avoidable Emergency Department Use: When Policy Expects Patients to Be Doctors,”
      • Jaffe T.A.
      • Kocher K.E.
      • Ghaferi A.A.
      Potentially avoidable emergency department use: when policy expects patients to be physicians.
      we discussed the challenges of appropriately treating patients with acute care needs and the concerns with restricting access related to “potentially avoidable” emergency department (ED) use. We first described the current health policy context and then highlighted a promising strategy from a collaboration between payers and providers for bariatric surgery patients.
      We appreciate that Lee et al
      • Lee J.
      • Greenspan P.T.
      • Israel E.
      • et al.
      Emergency department utilization report to decrease visits by pediatric gastroenterology patients.
      highlighted a critical component of our bariatric surgery initiative—Michigan Perioperative Initiative to Reduce Readmissions and ED Visits (M-PIRRE)—one that warrants further discussion: the role and responsibility of specialists. As the authors indicate, specialists play an extensive and increasing role not just in the management of acute illness but also in the longitudinal care of patients. As such, potentially avoidable ED visits are a shared responsibility across multiple practice settings and disciplines, including both primary and specialty care. The Michigan Perioperative Initiative work that resulted from careful data audit and feedback in the Michigan Bariatric Surgery Collaborative, a payer-funded collaborative quality improvement program, is very similar to the authors’ referenced work. Our Michigan Perioperative Initiative team conducted process-of-care analyses for each of the 42 participating sites to identify and address the underlying causes of avoidable ED visits. Best practices were identified, and sites were surveyed to assess compliance. Associations between rates of compliance and ED visit rates were then compared during the 30-day surgical episode.
      • Abdel Khalik H.
      • Stevens H.
      • Carlin A.M.
      • et al.
      Site-specific approach to reducing emergency department visits following surgery.
      Next, patient perspectives on ED use and specifically on self-referral to EDs were examined through targeted surveys and interviews. We found that patient education about symptoms, patient expectations, and alternative sources of timely care are key to help reduce potentially avoidable ED visits.
      • Stevens H.
      • Wells E.
      • Ross R.
      • et al.
      Patient perspectives on emergency department self-referral after bariatric surgery.
      Finally, interviews with surgeons and their practices yielded important insights into the relative comfort with alternative care settings and knowledge about their availability. All of these components together have yielded the multipronged approach of patient and provider education that we hope will continue to decrease potentially avoidable ED visits in this subspecialty patient population.
      Fundamentally, meeting the acute care needs of patients should be patient centered and cost-effective.
      • Kocher K.E.
      • Ayanian J.Z.
      Flipping the script: a patient-centered approach to fixing acute care.
      This challenge requires shared responsibility and collaboration across multiple stakeholders, as evidenced by our work in the Michigan Bariatric Surgery Collaborative and the authors’ work with pediatric gastroenterologists. Specialist support for patients is one component in reaching the ultimate goal of providing timely, accessible care for those conditions amenable to treatment in alternative locations to the ED.

      References

        • Jaffe T.A.
        • Kocher K.E.
        • Ghaferi A.A.
        Potentially avoidable emergency department use: when policy expects patients to be physicians.
        Ann Emerg Med. 2018; 72: 256-258
        • Lee J.
        • Greenspan P.T.
        • Israel E.
        • et al.
        Emergency department utilization report to decrease visits by pediatric gastroenterology patients.
        Pediatrics. 2016; 138: e20153586
        • Abdel Khalik H.
        • Stevens H.
        • Carlin A.M.
        • et al.
        Site-specific approach to reducing emergency department visits following surgery.
        Ann Surg. 2018; 267: 721-726
        • Stevens H.
        • Wells E.
        • Ross R.
        • et al.
        Patient perspectives on emergency department self-referral after bariatric surgery.
        Surg Obes Relat Dis. 2018; 14: 674-681
        • Kocher K.E.
        • Ayanian J.Z.
        Flipping the script: a patient-centered approach to fixing acute care.
        N Engl J Med. 2016; 375: 915-917

      Linked Article

      • Potentially Avoidable Emergency Department Use: When Policy Expects Patients to be Physicians
        Annals of Emergency MedicineVol. 72Issue 3
        • Preview
          Identifying and preventing avoidable use of the emergency department (ED) may provide substantial cost savings. One study suggested approximately one fifth of US ED visit episode costs could be avoidable, with an annual estimated expense of greater than $60 billion.1 Considering the cost associated with ED use, payers have embarked on policies with the goal of reducing what is perceived as inappropriate ED visits. These strategies have put patients at greater financial risk and have faced scrutiny from the medical community.
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      • Reducing Emergency Department Utilization by Engaging Specialists
        Annals of Emergency MedicineVol. 72Issue 6
        • Preview
          The article by Jaffe et al1 nicely describes the strategies at reducing avoidable emergency department (ED) visits. We believe that in addition to their proposed “provider-side” interventions, involvement of specialist clinicians is also crucial. Although the interventions described by the authors focus on ED and primary care practices, our US health care system continues to specialize (and subspecialize). As of 2015, 49% of physician office visits were to specialists, with approximately half of these visits related to routine and follow-up care and not to referrals or new patients.
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        • PDF