To ED or not to ED: a phone call will not answer

The demands placed on the health system are increasing faster than population growth. Demand for services in emergency departments (EDs) increased 3.2% per annum in the 5 years to 2010–11.1

The present model of service delivery is unsustainable and changes are required. What is not clear is what these changes should be. There are two competing positions: one supports increasing the bed base,2 the other supports providing innovative models of care.3

Many hospital-avoidance solutions have been proposed: walk-in nurse practitioner clinics, GP Super Clinics, hospital-in-the-home programs, telehealth for rural areas, and telephone advice lines. These programs have been greeted warmly by the media and politicians as ways of reducing demand for hospital services. However, evaluation of whether they deliver the outcomes they promise has been limited.

In this issue of the Journal, Ng and colleagues use Western Australian data to review the effectiveness of one of these programs — healthdirect Australia (a free 24-hour telephone triage, health advice and health information service).4 The premise of the study is that the success or failure of the program should be measured not by the volume of calls to the service, but by the “appropriateness” of the outcomes of these interactions. The outcomes were defined as one or more of the following: admission to hospital, referral to an inpatient unit, referral to an outpatient clinic, transfer to another hospital, death in the ED, or performance of diagnostic investigations. A comparison was made between healthdirect referrals to the ED, self-referrals to the ED, and general practitioner referrals to the ED.

One limitation of this approach is that the construct of appropriateness may not map perfectly with either the need to attend an ED or admission to hospital. Notwithstanding this, the findings raise questions about the program’s value and permit the following observations. raise questions about the program’s value and permit the following observations.

Patients whom healthdirect recommended attend the ED were not found to differ in appropriateness from those whom it recommended go elsewhere. There are three possible explanations for this. First, healthdirect may be limited in its capacity to distinguish those who need to attend an ED from those who do not. Second, the appropriateness construct may be unable to make this distinction. Third, the patient group that healthdirect referred to the ED may be appropriate for either an ED or a general practice. The first and third of these explanations suggest that healthdirect is of limited value in determining the need for a patient to attend an ED, while the second limits the value of the study.

The study also found that patients attended the ED even after healthdirect informed them that their condition did not require that level of care and that they could wait for a GP.

The role of the GP in providing care for primary care patients was confirmed in this study. GP referrals were more appropriate than self-referrals and healthdirect referrals. Unfortunately, the availability of GPs is declining, particularly after hours.5

People who come to an ED seem to know what they are doing and make good choices without telephone advice.6 Widespread community awareness of the delays attendant in presenting to an ED7 suggests that those who go to an ED with less urgent conditions may be making an informed choice and weighing up the alternatives available to them.8 In Ng et al’s study, the self-referred group had the highest proportion of seriously unwell patients.4

Humans are risk averse and overvalue strategies that they perceive will mitigate remote risks.9 The healthdirect service may be perceived by the community as such a strategy, and thereby be attractive to politicians who want to demonstrate that they are addressing health care access issues. However, low-acuity patients are not the major problem facing EDs. Patients with less urgent conditions are treated in EDs at marginal cost only after more seriously unwell patients have received care.10

It is not enough that new services expand the range of medical services available to patients. They must be evaluated, not in terms of activity, but in terms of the efficiencies they bring to the system in which they operate. Hospital-in-the-home programs are sometimes justified on the basis that they “save bed-days”. This argument is only valid if beds can actually be closed and savings realised.

Consideration must be given to whether healthdirect represents the best use of finite health dollars. It is not clear that, if offered an informed choice, the community would choose to pay for telephone advice that makes little difference to their behaviour over other health service priorities. In relation to whether an ED visit is required, it appears that a phone call will not answer the question.