SAN ANTONIO – When the Family Medical Center of Johnstown, Pa., encouraged patients to use its services for nonemergency care – instead of the nearby Memorial Medical Center emergency department – the number of center patients using the ED declined .
The results of the intervention were presented in a poster by Dr. Jeanne Spencer and Dr. Rashmin Adesara at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine. The conference was also sponsored by the American Academy of Family Physicians.
The reminders came in the form of posters mounted in the Family Medical Center (FMC), a residency program with about 1,000 patient visits per month, plus follow-up letters to FMC patients who had used the ED for routine care during FMC operating hours.
Like most EDs, "[Memorial Medical Center] is overcrowded, and at times the wait times are longer than we want. We all recognized some of the people going to the [ED] would have been better served coming to our office. We were trying to encourage them to come to the FMC," said the center’s director, Dr. Spencer, in an interview.
Some FMC patients were visiting the ED two to three times per month, either out of habit, because they were not aware that the center had same-day appointments, or because they assumed they would get better care in the ED, according to Dr. Adesara, who was a third-year FMC resident when he tackled the problem with Dr. Spencer’s help.
Money probably wasn’t the issue. Medicaid patients – the focus of the intervention – had no copay in the ED, but only a $2-$3 copay at the FMC, Dr. Adesara said, also in an interview.
The posters – a large one in the waiting room, smaller versions in the exam rooms – were hung in July 2009.
"We are here for you" was the message stated prominently on the posters.
The posters asked patients to call FMC for nonemergencies before going to the ED, and displayed the FMC’s telephone number. Patients were also reminded they’d be treated more quickly at the center, and by doctors who knew their medical histories.
Those who went to the ED anyway for nonurgent care got Dr. Spencer’s letter, after they were identified by Dr. Adesara’s record reviews.
"As your primary care physician, we came to know that you recently visited the emergency room. We hope that you are feeling better now," the form letter began.
It reemphasized the poster message, and mentioned the same-day appointments.
"Next time you have a problem like back pain, ear ache, nausea, diarrhea, sinus infection, [or] sore throat, call us before going to the emergency room. In most cases, we will be able to schedule you an appointment that meets your needs," the letter concluded.
Dr. Adesara sent 316 letters from July to the end of September; only two people complained, insisting their ED visits had been emergencies.
To assess the impact of the interventions, he compared the percentage of Memorial Medical Center ED visits by FMC patients from April to June 2009 – the period before the posters went up and the letters went out – to their percentage from October to December 2009, the postintervention period.
FMC patients accounted for about 7% of 17,865 total emergency room visits from April to June. The percentage began to decline during the intervention period, and then stabilized at about 6% of 17,363 ED visits from October to December.
Meanwhile, the percentage of patients from an internal medicine clinic in FMC’s building – which served as a control in the study – increased slightly from about 1.3% to 1.4% of ED visits over the same period.
"Our intervention appears to have resulted in a decrease in total ED utilization by our patients," Dr. Spencer and Dr. Adesara concluded in a poster displaying the study results.
"Putting up the posters is very quick and inexpensive. We bought our large poster for $25," she said. They are still up in the FMC.
Likewise, "if you see somebody going to the [ED] all the time, it might be pretty easy to have a staff person send them a quick letter to encourage them to come to the office rather than the [ED]," she said.
The study had no external funding and the investigators reported no conflicts of interest.