Correspondence

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

American Journal of Emergency Medicine 34 (2016) 307-337

Homelessness and ED use: myths and facts

To the Editor,

In their article, “The role of Charity care and primary care physician assignment on ED use in Homeless patients” [1], Wang et al perpetuate a myth about homeless emergency department (ED) patients that is not supported by the evidence. Namely, in their introduction they state, “… these patients tend to inappropriately use the ED more often than the general population,” yet this statement has not been supported by prior research. None of the 3 articles they reference for this statement (one of which I coauthored) studied “inappropriate” vs “appropriate” use of the ED. Although it is true that research has shown that people who are homeless tend to use the ED more often than people who are not homeless, we cannot assume that their ED use is more often “inap- propriate.” Because Wang et al did not examine the proportion of “inap- propriate” ED visits for nonhomeless ED patients, they cannot comment on whether people who are homeless use the ED more or less “inappro- priately” than other patients. Finally, research has called into question the advisability of even trying to categorize ED visits as “inappropriate” vs “appropriate,” [2] with some leaders in the field suggesting that we “put to rest conversations about ‘inappropriate’ ED use [3].”

These concerns noted, Wang et al should be commended for their methodology of matching electronic health record data with local Homeless Management Information System data and for seeking to learn more about homeless patients in their health care system. They also succeed in beginning to dispel the alluring (yet so far not evidence based) tale that primary care will reduce ED use by showing that Access to a primary care provider and charity care alone were not associated with reduced ED use among people who are homeless in their study.

Kelly M. Doran, MD, MHS Departments of Emergency Medicine and population health NYU School of Medicine/Bellevue Hospital Center, New York, NY 10016

Corresponding author. Tel.: +1 212 263 5850

E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2015.10.001

References

1. Wang H, Nejtek VA, Zieger D, Robinson RD, Schrader CD, Phariss C, et al. The role of charity care and primary care physician assignment on ED use in homeless patients. Am J Emerg Med 2015;33:1006-11.
2. Raven MC, Lowe RA, Maselli J, Hsia RY. Comparison of presenting complaint vs. dis- charge diagnosis for identifying “nonemergency” emergency department visits. JAMA 2013;309(11):1145-53.
3. Bernstein SL. Frequent emergency department visitors: the end of inappropriateness. Ann Emerg Med 2006;48(1):18-20.

   Homelessness and ED use: myths and facts- the author’s reply

   In Reply:

   

   We would like to thank Dr Doran for the commentary regarding our recent publication, “The role of charity care and primary care physician as- signment on ED use in homeless patients” [1]. The primary goal of our study was not to compare homeless patients with the general population, but to compare emergency department (ED) use in a homeless popula- tion as a function of whether they received charity care or were assigned to a Primary care physician . Our rationale to conduct this compari- son study grew out of our desire to better serve these patients by assigning homeless patients to a PCP rather than have them receive care by a variety of different rotating emergency physicians. We felt that a “continuity of care” model might be an important mitigating factor as charity care clinic patients do not often have the opportunity to establish a solid relationship through scheduled care with the clinic doctor(s).

   In addition, although we appreciate Dr Doran’s comment that inap- propriate ED visits in homeless patients isa “myth,” we must point out that our terminology of appropriateness was a direct reflection of our use of the New York University ED Algorithm. “Inappropriate” ED use in the introduction of this study was operationally defined as (1) prima- ry care treatable, (2) Emergent care needed but preventable or avoid- able, or (3) nonemergent condition as per the New York University ED Algorithm. To clarify the data from our study, we have provided further evidence that the homeless patients using our county-funded hospital network indeed have a high percentage of inappropriate ED visits for nonurgent care that could have been better treated with an outpatient PCP who would be available to provide ongoing follow-up (see Table). We concur with Dr Doran that the data from Levy and O’Connell [2], Hwang et al [3], and Tsai et al [4] showed that more ED visits occurred in homeless patients than in the nonhomeless population (either general or US veterans). However, the question of whether or not these visits were inappropriate was not studied. Therefore, those studies should be viewed as concluding that “homeless patients tend to use the ED more often than the general population.” We acknowledge the chal- lenge of categorizing appropriate ED use and agree that language such

   as “inappropriate ED utilization” should be used with caution.

   Table Most common discharge diagnoses among homeless patients who were considered to in- appropriately use the ED

   Primary discharge diagnosis %

   Chronic pain (extremities) 15.5

   upper respiratory infection 11.9

   Chronic back pain 9.2

   Unspecified Essential hypertension or diabetes 6.8

   Prescription refills 4.3

   0735-6757/(C) 2015