15 January 2008

From the Journal of Proving the Intiutively Obvious

Blogging on Peer-Reviewed ResearchI don't know why it is, but for some reason, a large proportion of Emergency Medicine research makes me roll my eyes and mutter, "well, duh!" under my breath. Like the paper I read a number of years ago which demonstrated, with ample citations, that being on a backboard hurts. "Well, duh!" Ever been on one? Ever seen poor trauma patients strapped to the board begging to be let off? We needed a peer-reviewed paper to establish that fact? (Using the Visual Analog Scale (VAS) for pain.) Geez.

Well, another one hit the press today. Not as inane, but every little bit as obvious, IMHO, to anybody who has set foot in an ER over the last decade. Apparently, the average waiting times in ERs can sometimes get a bit long, and are increasing. Given the fact that since 1994 the number of ER's in the US has decreased from 5000 to 4500 and the number of ER visits has gone up 25% (from 90 Million to 115 Million), what else would any rational person expect?

Sarcasm aside, this is important research. Add it to the pile, on top of the IOM report and the rest of the data showing that the nation's ERs are in crisis.

This study resembles one I blogged on last week, in that it represents some interesting data mining of the NAMCS database (did this just become available or something?), again to good effect. The results showed that the average wait time in the ER increased about 4% per year over the seven-year study period, and, interestingly, that patients with heart attacks had wait times that increased 12% per year (despite a huge increase in awareness of the "time is muscle" concept and Medicare's focus on the door-to-dilation time for heart attack patients). The overall wait time increase was more than a third: 36%, This was consistent with the wait time increase for patients triaged "Emergent" -- 40%, and heart attack (AMI) patients' waits increased a staggering 150%. No explanation is given as to why AMI patients had a larger proportionate increase in wait times... an odd omission given the importance of the topic, but then, data-mining is good for finding problems, not so great for pinpointing the causes.

Whitecoat will probably be annoyed to find that the study noted another example of racial disparity in the longer wait times for minorities. In this case, this may be accounted for by the fact that wait times were longer at urban and academic EDs, though the authors do not draw that exact conclusion. And unlike the other study I blogged, apparently, payor status had a large effect on quality of care -- wait times increased by 50%. The authors are not entirely clear whether that may be due to the urban hospital effect, though one would hope a decent multivariate regression analysis would sort that out. The crosstabs are missing, also, and uninsured patients are more likely to show up with less-urgent complaints, so that may account for the longer wait times by the uninsured.

Nonprofit hospitals, unsuprisingly, fared worse than for-profit hospitals. This is by no means a validation of the profit motive in providing health care, but, I suspect, more due to the fact the nonprofits tend to care for underserved populations and have less resources to expand their service capacity to meet demand.

Also interestingly, the average urgency of ER visits declined. This is consistent with the general impression that more people are using the ER for their primary care. While not exactly desirable, this is indeed consistent with our Dear Leader's idea of Universal Health Care.

Don't be deceived by the relatively "short" wait times cited -- many in the 15-30 minute range. These are average times, and remember that for one patient seen on arrival (say, a patient arriving by ambulance, a detail not referenced in the paper), there's another who waited an hour or more. Our ED has an average door-to-doctor time of about 25 minutes, and we are rather proud of that fact, but there are still days when the waiting time is three hours. So averaging can make the ER look better than it really is.

Ultimately, there's no real take-home point beyond that encapsulated in the headline. The nation's ERs are in crisis -- over-burdened, under-funded, beset by the collapse of primary care, and hamstrung by the scarcity of inpatient hospital beds. How much longer will it take before the policy-makers wake up and do something to avert the impending catastrophe? I first heard about this via a diary on Daily Kos, and the author took exception to the fact that a mass-casualty incident such as a terrorist attack was cited as a potential threat. But when you look at the the ED, and its role in disaster preparedness for unlikely events such as terrorist attacks, pandemic influenza, SARS, etc, you realize how thin the line is separating a "shitty but functioning system" from "complete and total collapse." And being a paranoid ER doc, my job is to assume the worst-case scenario and proceed as if it is the case.

Kevin and some others like to scream about CanadaCare and other bogeymen of the healthcare wonk set, but, really which is more emblematic of a broken health care system: the system which requires long waits for elective surgery, or that which progressively fails to care for heart attacks in a timely fashion?

citation: Health Affairs, Waits To See An Emergency Department Physician: U.S. Trends And Predictors, 1997-2004;
DOI: 10.1377/hlthaff.27.2.w84


  1. It's me, hobbitfoot, from dkos.

    I took part in our little community's disaster preparedness committee. Bottom line, if some major disaster strikes (terrorist-inspired or Act of God), we're hosed. Not enough beds, not enough ventilators, not enough practitioners, not even enough IV fluids. We would be using the fair grounds, the schools, the fire departments, any place we could think of which could be turned into a temp hospital.

    The EDs would get overwhelmed, but so would the whole system.

    Nice to meet you, by the way!

  2. PS: you're in the Pacific Northwest? How uncanny! I live in Brookings, OR.

  3. I too was amused by the medias stunning announcement regarding increased waiting times in ED's.

    I was also amused by what was not discussed. In the ED's I have worked in the doctor is usually the last person to see a critical patient. If you have a good staff, Nurses get the labs started, appropriate tests ordered, ACLS protocols activated and more recently Chest Pain pathways and protocols.

    Are they getting more crowded? Yup. Are wait times increasing? Most of the time, even with things like XPress Care, ER Staz or whatever the in house "Doc in the Box" is called this month.

    Instead of continually berating the healthcare community for our shortcomings maybe showing how we have learned to "do" with what we got might also get more soldiers in the fight on our side.

    BTW I also am a Northwestener (Idaho). ED Nurse 20+ years.

  4. Door-to-doctor in 25 minutes? I had a dream like that once.

  5. Kevin and some others like to scream about CanadaCare and other bogeymen of the healthcare wonk set, but, really which is more emblematic of a broken health care system: the system which requires long waits for elective surgery, or that which progressively fails to care for heart attacks in a timely fashion?

    I hate to be the one to break this to you, Shadowfax, but Canada also has ER wait time issues, as referenced in this article. Here’s the money quote:

    "A recent survey published in the journal Health Affairs examined wait times for ERs in several nations and found that … only 39 per cent of Canadian respondents waited less than one hour to be seen in the ER … 24 per cent of Canadians reported ER waits of four hours or more ..."

  6. HI!

    From what I can gather, you clearly should have been a radiologist. Patient contact, the 'system', your self-admitted 'bullshit detector'...these things lead to the conclusion that you are a very unhappy individual.

    I haven't even touched on the fact that you have a deep need for social acceptance.

    Let me put your mind at ease- you're cool. Ok? You're very smart and aware. Personally, I wouldn't be at all be disappointed if you were my ED doc.

    However, I'm more than happy to report that you're not my friend/relative/colleague. I mean, Jesus man- does it ever end?? Does your wife sigh with relief when you finally go off to a job that you bitch about constantly?

    No. And, I'm fairly positive, yes.

    Wouldn't you be happier sitting in front of your computer, (where you can blog your ass off), and receive cases where you just talk into a digital recorder and send them off to be transcribed?

    Think about it, man.




  7. Chris,

    Thanks for your concern, but I am in fact fairly happy and well-adjusted both personally and professionally. The only thing that makes me envious of radiologists (besides the huge piles of hundred-dollar bills they go home and roll in) is the cool gadgets they get to play with, especially the IR guys.

    As for being "cool," well, I may be socially accepted and successful, but I am under no illusions about being cool. As dave barry once put it, the light leaving "cool" right now will take millions of years to get to me. Oh well. I can live with it.

    I suspect, if you find me bitter and cynical, you must not have spent much time on medblogs. I'm on the happy end of the spectrum. Go read Panda, Scalpel, WhiteCoat, and the Happy Hospitalist. Then come back and tell me how much I must hate my job!

  8. Catron,

    Good point. I knew that but must have suppressed it when I was writing that sentence.

    Still, just because it sucks worse in Canada doesn't make our system failures acceptable...

  9. I don't think you hate anything.

    I think you're good at what you do, and hey- that's enough.

    Just...hearing you complain. It's difficult to discern whether you're trying to impress us with your intelligence, (natch), or simply bitching about the obvious.

    What exactly is your point here? It is the prerogative of children and half-wits to point out the emperor has no clothes. Yet the emperor remains an emperor and the half-wit remains a half-wit. *

    Sir, your chosen profession brings out the best and worst of the human condition. I know a UPS man that could say the same thing.

    The drug-seeker will always be a drug-seeker, the media will always be the media, the guy that's on the table and coding....you get the idea.

    Now that we're done jerking each other off, wouldn't it be nice to talk about solutions?

    Yeah, I know....fuckit.



  10. * = directly ripped off from Neil Gaiman.

  11. Hiya,

    Interesting post -- what it made me wonder was, given that average wait times are inaccurate for the reasons you stated, why isn't the median used? It might better approximate the experience of most people? Or some more sophisticated method of quantifying the distribution?

  12. Alexandra Lynch1/25/2008 10:53 AM

    The problem is is there isn't any one to go see about the fact that the pain that has sort of been background all day has now ramped up to where you can't sleep and now you're worried that maybe something is Really Wrong...at one or two am.

    If we have to take my husband to medical care when he gets off work, it will be the ER, because he works three to eleven, has an hour commute home, and nothing but the ER is available at midnight. Sorry, everyone.

    But given that, ok, we'll wait, bring books, a bottle of water. It's the nature of the beast.

  13. Think about this.
    If you really did find a working formula that made you, say $1,000 a week online on average and it kept producing income no matter what, would you want to sell that idea to a bunch of noobs for $47 a pop and expect to retire on the proceeds? No way, man! It does not compute. It does not add up. And it does not make any sense to do that. I certainly don’t go shouting from the rooftops how I make my money online. Hell, I don’t want the competition taking a slice of my pie and neither would anyone who really does make good cash online.


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