Despite all of our efforts over the past decades to build medical homes for our patients and families and to connect them to their new homes, people still choose emergency rooms (ERs) for ambulatory care.
As an example, in a study utilizing the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Hospital Discharge Survey (NHDS) to assess hospital-associated healthcare between 1996 and 2010 in the US, the number of ER visits increased by 44%, resulting in an average 48% of contacts (comparing hospital outpatient departments, emergency departments, and ambulatory surgery sites).
In this study the rise was significantly greater in African-American populations, Medicare and Medicaid recipients and in women, emphasizing the important use of ERs by traditionally vulnerable, urban populations (Marcozzi et al. Intern; Int J Health Serv. 2018;48:267-288). In Baltimore City there were 52 ER visits/1000 patients per month and 28/1000/month in the State of Maryland as a whole in 2018 (CRISP). Earlier studies using the ecology of health care model suggested a generalized rate of 13/1000 ER visits per month for the US population (Green et al. NEJM 2001;344:2021-2025). It seems that people are choosing ERs more often.
Conversations about ER visits by urban low socioeconomic patients usually devolve quickly to questions of how to decrease this “inappropriate” utilization and to direct care to other, less expensive ambulatory settings. It is the application of “lower-case p” population health; a perspective that examines a population health issue primarily from a health system’s perspective rather than the perspective of the patient, family or community. Perhaps as a result of our intrinsic insider bias, we are asking the wrong questions.
The Emergency Medicine Patients’ Access to Healthcare (EMPATH) study collected information at 28 different US hospitals over a 24-hour period using a standardized interview format. The sample represented a diverse range of geographic areas and demographic groups and found that patients chose the emergency room because they perceived it to be the best place for them to receive care; for the ER’s convenience of access, continuity, range of available services, and the affordability of the care (Rogin FR et al. Acad Em Med 2005;12:1158-1166).
A qualitative study of patients with low socioeconomic status using an urban ER found similar patient preference, although the authors recognized distinct population profiles of patients who used the ER for ambulatory care. The authors concluded, “Patients articulated clear, logical reasons for preferring hospital to ambulatory care. The reasons provided cannot be attributed to a cultural tendency or ignorance remediable by education on the appropriate use of the ED” (Kangovi S. Health Aff 2013;32:1196-1203).
The “job to be done” is one of the key principles in the theory of disruptive innovation championed by Clay Christensen and others at the Harvard Business School. “The concept explains how customers want to ‘hire’ a product to do a job.” As professor Theodore Levitt argues, “People don’t want a quarter-inch drill. They want a quarter-inch hole.”
Christensen articulated this theory in his “milkshake” example. After failing to impact sales of milkshakes for a restaurant chain, he interviewed customers in specific demographics to determine the “job” that they wanted the milkshake to do. For one group of morning commuters he found that milkshakes were purchased by customers who wanted something to consume while driving; something neat and tidy that would take the duration of the drive and would keep them from feeling hungry before lunch. Sales increased after adjusting the product to address the “job to be done” in this group of customers.
Research suggests that patients are willing to endure the long wait times in ERs because they want care that fits their schedule and is available 24/7 with providers who can handle everything from a diaper-rash to a heart attack. They want care in a place that has the full range of the lab, imaging and specialist access they think (or fear) they might need rather than having to miss work and arrange transportation to pursue follow-up visits to other sites for studies or consultations. They want care where the up-front cost is low, and where they know that if they have been there before, the providers will have full access to all their medical information. We think of primary care as the quarter inch drill. But our patients are telling us that the ER is the quarter inch hole.
Perhaps a medical home that is has similar accessibility and continuity across care settings, proximity to the full range of possibly needed hospital services and specialists, the availability of critical medical records and no up-front co-pay would address what patients are telling us they are looking for. It will require a different way of thinking, different practice policies and different options for health care financing.
Until then our patients will continue to visit the ER, the best place for their “job to be done.”
Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.wordpress.com/
Henry V 4.3 
As always, great insight. Now doing primary care pediatrics in the private sector, rather than the military environment, I see these similar patterns at play. The model of care and access to primary care is different from and does not necessarily meet the patients’ wants or needs. I have even seen this play out with family members who I believe would be best served seeing their PCP but, for myriad reasons, end up in Urgent Care or the ED because that setting gets the job done where the PCP could not. I also notice there is a stark difference in how the medical professionals access and utilize care from the “average” patient. I am sure this reflects both mindset and system issues and access preferences, so that the PCP gets the job done for us but not always for those we should be serving.