What's the Big Emergency?Zachary F. Meisel and Jesse M. Pines take readers' questions about E.R. abuse and its culprits.

(Continued from page 3)

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Dr. Jesse M. Pines: Agree. Emergency physicians tend to think of the worse case scenario when they are seeing patients and make sure that all the emergencies are ruled out.

Much like if you show a rash to a dermatologist, he'll say 'rash' but if you show a rash to an oncologist, he'll say 'cancer'.

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However, our article stated that the uninsured are just as likely to use the ED as the insured, indicating that it is more of an urgent access issue than an uninsurance one.: But couldn't that simply be because the uninsured wait longer and sometimes just stay sick? And doesn't this increase costs in the long run?

Dr. Jesse M. Pines: Yes, absolutely. When people wait longer to be seen, if it is a treatable illness (like an infection), sometime they end up sicker in the end and require more resources. Same goes when people don't see primary care doctors, they don't get preventive services like blood pressure management and cholesterol lowering which can prevent heart attacks and strokes.

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Re: Uninsured using the ER: How many of the emergencies for which the uninsured use the ER were preventable, if they had had insurance? My guess is that "abuse" of the ER isn't the problem; it's that lack of insurance turns molehills into mountains.

Dr. Jesse M. Pines: Agreed. Lack of health insurance certainly makes the health of the population worse because they don't get preventive care. I'm not sure anyone has actually quantified the burden of preventable disease caused by uninsurance.

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Menomonie, Wis.: Good morning. I am not sure if this is off-topic, but I often have heard the term, "clinical futility." Do you know what this term means? Thank you.

Dr. Jesse M. Pines: That is somewhat off-topic, but clinical futility refers to when additional resources allocated to a patient's care will not change a poor outcome, for example, when there is brain death.

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Re: Laurel, Md.: I did a paper last year on this very subject, and believe it or not, American citizens are the worst offenders in using the ER as their own doctor's office. As Dr. Pines and Meisel stated, it is not just one-sided. If you read something that seems logical but may be considered racist, investigate the statement more thoroughly. There are many sites out there that give a truer picture of what is going on.

Dr. Jesse M. Pines: We certainly know that ER visits are going up—67 million in 1996 and 119 million in 2006 in the U.S. Critical thinking about the topic and getting to the heart of who is using the ER and why will hopefully point us to solutions.

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Washington: I work evenings/weekends as a telephone triage/advice nurse for an HMO with urgent care clinics open 24-7. Many callers with non-urgent conditions (e.g. rash unchanged for the past two weeks) want to go there or to an ER because they don't have any sick leave coverage at work, rely on public transportation and an unaffiliated ER is "just down the street," or they "just got tired of [the condition]" and want it fixed now (however unlikely that is). All are frustrating from "the system" viewpoint, but at least I have sympathy for the first two. Any suggestions for how to dissuade the third group from using "urgent" care settings for nonurgent problems, which slow response time for everyone else?

Dr. Zachary F. Meisel: Well first it is great that you have this job—I bet you are able to help people sort out whether or not they need to go to the ER (can you schedule urgent or follow up appointments?) So the answer may be creating more positions like yours and training those who staff it how to do a good job triaging patients by phone. But we still have to convince the patients to use the phone service and not just go to the ER because its there or its cheap. As we mentioned in the article, raising cost sharing for ER use (through higher co-pays) may help (but it won't be popular). However, people are already likely paying for low co-pays through their insurance premiums. So raising co-pays may not actually drive more out of pocket health consumer costs.

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Dr. Zachary F. Meisel: Thanks everybody for the great questions.

Dr. Jesse M. Pines: Excellent questions, goodbye everyone.

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