Every wondered why emergency departments in the USA are so crowded? The answer seems to be in people's changing behaviors over the last few years. Today, only 45% of the 354 million yearly visits for acute care in the USA are made to the patient's personal doctor, while an enormous number are going straight to emergency departments, seeing specialists, or turning up at outpatient care departments as their first point of call for treatment for new health problems, episodes, or a flare-up of a chronic health condition, such as diabetes or asthma.

Put simply, for readers outside the USA - Americans are seeing their GP (general practitioner) less and less and going straight to hospital as their first point of call more and more often.

A study found more than a quarter of all acute care visits in US now made to emergency departments.

This is not good news for America's often understaffed and extremely busy emergency rooms, according to an article published in Health Affairs. Fewer than 5% of American doctors are emergency physicians Emergency physicians handle over 28% of all acute care encounters in the country Over 50% of acute care visits by the under- and uninsured are handled by emergency physicians in America According to the authors, health reform provisions in the Patient Protection and Affordable Care Act were included so that advance patient-centered medical homes and accountable care organizations could improve access to acute care. However, the challenge for reform, according to study authors, will be to succeed in the complex acute care landscape that already exists.

Co-author, Steven Pitts, MD, associate professor of medicine in the Emory School of Medicine and a staff physician at Emory University Hospital Midtown, wrote:

Timely access to care is important, especially for those who are acutely ill. First-contact care has been a central tenet of primary care. But over the past few decades, the focus of primary care has shifted as a result of a growing elderly population, the growing burden of chronic disease and the challenge of coordinating care across multiple physicians. Low rates of reimbursement have accelerated this trend by forcing many primary care physicians to pack their daily schedules with 15-minute office visits - leaving little time for patients with acute health problems.

The study spanned from the beginning of 2001 through to the end of 2004. It showed that in America: An average of 1.09 billion outpatient visits were made annually to physicians On average, there were 321 visits per 1,000 people each month 351 million encounters per year were for acute care - treatment of new problems or a flare-up of a chronic health condition. 22% of acute care visits were dealt with by a GP (general practitioner, primary care physician) 10% of acute care visits were dealt with by a general internist 13% of acute care visits were dealt with by a pediatrician. A significant number involved treatment for minor upper respiratory conditions, such as a sore throat or a cough. Specialists in their own practices handled 20% of acute care visits, generally for their specialized medical areas, such as skin, eyes or orthopedic problems. 28% of acute care visits were dealt with by hospital emergency departments; mostly for more complex and potentially dangerous conditions, such as fever, chest pain, or stomach and/or abdominal pain. Co-author, Arthur Kellermann, MD, the Paul O'Neill Alcoa Chair in Policy Analysis at the RAND Corporation and previous associate dean for health policy at Emory University, said:

One of the biggest barriers to providing acute care in primary care practice is that many primary care doctors have packed schedules. This makes "same day" scheduling, much less treatment of walk-in patients, extremely difficult.

"Busy schedules also discourage primary care physicians from taking the time they need to treat patients with complex, undifferentiated complaints. It is faster and simpler to refer them to a specialist or the nearest emergency department. Ensuring timely access to primary care is a desirable goal, because it increases a person's odds of finding a "medical home". Unfortunately, for many years now, primary care in the U.S. has been in decline. Patients have adapted by seeking care elsewhere when they get sick.

Pitts added:

Our data indicate that more than half of acute visits today involve a doctor other than the patient's personal physician. Dr. Pitts adds, "More than a quarter of all acute care visits, including virtually all weekend and "after hours" encounters, occur in hospital emergency departments. Heavy use of emergency departments for problems that a primary care provider could treat, if their patients could get in to see them, is not desirable from a societal perspective. Too often, emergency care is disconnected from patients' ongoing health care needs.

When your life is on the line, emergency departments are vital, Kellerman commented. When they can't get care elsewhere, Americans know that there is always a doctor on duty in the ER.

Kellerman said:

Strengthening primary care is a major goal of healthcare reform. If successful, it will be a win for everybody.

"Emergency Department Use - Where Americans Get Acute Care: Increasingly, It's Not At Their Doctor's Office"
Stephen R. Pitts, Emily R. Carrier, Eugene C. Rich and Arthur L. Kellermann
Health Affairs, 29, no. 9 (2010): 1620-1629
doi: 10.1377/hlthaff.2009.1026