Emergency Medicine and Public Health: Stopping Emergencies ...

Emergency Medicine and Public Health: Stopping Emergencies Before the 9-1-1 Call Arthur L. Kellermann, MD, MPH

P

ractitioners of emergency medicine (EM) are all too familiar with the challenges facing our emergency care system—challenges amply documented in a variety of governmental and nongovernmental reports.1–3 Across the country, we struggle with crowded conditions that hinder us from rendering timely care to our patients, increase the risk of medical errors, and contribute to adverse outcomes.4 Inbound ambulances are diverted roughly 500,000 times per year.5 Fewer and fewer specialists are willing to take emergency department (ED) calls.6 These problems are largely the result of broad societal forces that are shaping America’s health care system. The United States is unique among wealthy nations for having such a large percentage of its population without health insurance.7 For most of the past three decades, the number of uninsured has grown in good times as well as bad.8 Since the last census, about 7 million Americans have lost their jobs. Because a one-percentage-point increase in the unemployment rate boosts Medicaid and the State Children’s Health Insurance Program (SCHIP) enrollment by 1 million (600,000 children and 400,000 nonelderly adults), and the number of uninsured by 1 million, the current count of uninsured is probably close to 50 million Americans—a staggering number.9 RISING COSTS The challenges posed by the recession are compounded by the skyrocketing cost of medical care. In industries such as agriculture, computers, and manufacturing, advances in technology lower overall costs. In health care, the opposite is true—advances in technology almost always increase costs. This is a major reason why the average American household today spends more on medical care than food, clothing, or housing.10 From the Department of Emergency Medicine and Office of the Dean, Emory School of Medicine, Atlanta, GA. Received August 19, 2009; accepted August 20, 2009. Address for correspondence and reprints: Arthur L. Kellermann, MD, MPH; e-mail: [email protected]. Keynote presentation for the Academic Emergency Medicine consensus conference ‘‘Public Health in the ED: Surveillance, Screening, and Intervention,’’ New Orleans, LA, May 13, 2009.

1060

ISSN 1069-6563 PII ISSN 1069-6563583

High health care costs do more than provoke anxiety. A Commonwealth Fund study of comparative health system performance found that the United States scores poorly on measures of access to care. A higher percentage of Americans face financial barriers to care than citizens of New Zealand, Australia, Canada, or the United Kingdom. In the survey, access problems included ‘‘[d]id not get medical care because of cost of doctor’s visit, skipped medical test treatment or follow-up because of cost, or did not fill Rx or skipped doses because of cost.’’11 As emergency physicians (EPs), we know that such choices often result in an unplanned trip to the ED. Health care costs are eroding America’s ability to compete on the global market. Five years before General Motors slid into bankruptcy, the company’s chief executive officer reported that GM was spending $5.2 billion dollars per year on health care for its employees and retirees. Nearly 40% of this total, some $1.9 billion, was for pharmaceuticals.12 Over the past decade, the rising cost of benefits has offset productivity gains, keeping workers’ wages relatively stagnant.13 To limit expenses, many employers have started shifting the tab to their employees through higher copayments and deductibles. Some have cut costs by switching full-time employees to part-time or contractor status. Others have dropped coverage altogether. Health care costs are creating problems for the public sector as well. Many states spend more on health care than education—traditionally their top priority. Health care costs are also consuming a growing share of the federal budget. In fact, America spends an astounding 2.2 trillion dollars per year on health care—more than any other nation on earth. John Kitzhaber, an emergency medicine physician and former Governor of Oregon and an EP, likes to quote Denis Hayes of the Bullit foundation, who said ‘‘zeroes matter.’’ A million seconds ago was last week. A billion seconds ago Richard Nixon resigned the presidency. A trillion seconds ago was 30,000 BC!.14 America’s per-capita spending on health care is double the median among our global competitors—the 30 industrialized nations of the Organization for Economic Cooperation and Development (OECD). We also spend a larger share of our gross domestic product (GDP),

ª 2009 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2009.00567.x

ACAD EMERG MED • November 2009, Vol. 16, No. 11

•

www.aemj.org

and our costs are rising at a faster rate.15 Resources devoted to health care cannot be used to address other national priorities, including national defense, deficit reduction, and tax relief. A GRIM FUTURE In 2006, the Congressional Budget Office (CBO) projected what will happen if spending on Medicare, Medicaid, and private health insurance continues indefinitely at their average rates of growth from 1975 to 2005. Under these assumptions, the CBO determined that by 2082, combined public and private health care costs will consume 99% of the GDP.16 At that point, everyone will be a doctor, a nurse, or a patient. Obviously, this is an absurd notion. But it is equally clear that something dramatic must happen between now and then. UNCERTAIN VALUE Are we getting value for our money? It depends on who you ask. To be sure, America is unrivaled when it comes to biomedical science and high-tech care. We hold more Nobel Prizes in medicine than anyone. No country can match us when we pull out the stops for an individual patient. But too often, our health care system fails too many. In 2000, the World Health Organization (WHO) ranked us: • • • •

26th in the world for infant mortality; 24th in life expectancy; 37th in health system performance; and 40th in terms of the percentage of the population that is satisfied with its health care system.17

Studies suggest that approximately 1,000 Americans die each week because our care often fails to follow recommended practices. A recent international study of death rates from readily treatable health problems such as diabetes, hypertension, and pneumonia ranked us 19th of 19 wealthy nations—dead last.18 COVERAGE MATTERS The main reason we do poorly in international comparisons is because we strictly ration health care. Instead of rationing on the basis of high cost, or lack of anticipated benefit, we largely ration on the basis of the patient’s ability to pay. The wealthy and well-insured get plenty of care—sometimes, more than is good for them. The poor and the uninsured get less. On average, uninsured Americans get about half the medical care insured Americans receive. Studies show that the uninsured receive fewer preventive and screening services, and they receive them in a less timely manner. Uninsured cancer patients die sooner, mainly due to inadequate screening and delayed diagnosis. The uninsured receive less chronic disease care and poorer hospital care. Lack of timely and effective care takes a toll. An uninsured American’s risk of dying prematurely is 25% higher than that of Americans with health insurance.19 Lack of health insurance is not only a problem for the uninsured; it can compromise access to care

1061

throughout the community. Everyone is affected— insured and uninsured alike. Communities with high rates of uninsurance have difficulty recruiting and retaining physicians and other health care workers. In communities with high rates of uninsurance, hospitals are less likely to support vital but unprofitable programs, like trauma centers or emergency psychiatric units. In these communities, safety net hospitals struggle to survive.20,21 Uninsurance also causes problems for public health. Health departments may be forced to divert precious funds from core public health functions to support primary care clinics. Communicable disease control and emergency preparedness programs may be compromised.20 Remarkably, some assert that no one is really ‘‘uninsured,’’ because the Emergency Medical Treatment and Active Labor Act gives everyone a right to emergency care. President Bush said as much in a speech delivered in Cleveland, Ohio on July 10, 2007, when he quipped, ‘‘…people have access to care in America. After all, you just go to an emergency room.’’ THE POWER OF PREVENTION Clearly, the status quo is bad for our patients, bad for EM, and bad for our country. But what should be done? William Foege, former director of the Centers for Disease Control and Prevention (CDC) and one of the world’s most respected public health authorities, once told me, ‘‘It’s not hard to be brilliant. All you have to do is think of something stupid, and do the opposite.’’ It is stupid to ignore the deteriorating state of our health care system because everyone can go to an ED. It is stupid to ignore the economic impact of chronic disease. Ten percent of Medicare beneficiaries—the group with multiple chronic conditions—consume more than 60% of all Medicare spending. The bottom half consume less than 4%.22 It is stupid to ignore the importance of timely access to emergency care. Richard Feynman, Nobel Prize–winning physicist once said, ‘‘It takes very little energy to scramble an egg, and all our science is incapable of reversing the transaction.’’23 He could have observed that it takes very little time, too. Some of our colleagues believe that their job starts with the 9-1-1 call and carries through to ED disposition. But what if we intervened before the 9-1-1 call? What impact could we have then? In its report, Promoting Health, the Institute of Medicine (IOM) noted that 70% of the causes of death in the United States are due to behavioral or environmental factors, but less than 5% of annual spending on health care in the United States is directed toward reducing the health risks posed by these conditions.24 There are numerous determinants of health—genetics, of course, but also poorquality housing, income inequality, limited access to clean air and water, lack of education, discrimination, and risky behaviors such as smoking, high-fat diet, lack of exercise, and excessive consumption of alcohol. Public health, defined as ‘‘what society does collectively to assure the conditions for people to be healthy,’’ focuses on these factors and many others, including communicable diseases and injuries.

1062

Polls show that Americans support prevention. In 2008, Trust for America’s Health released the results of a poll that showed that 57% of likely voters believe that investing in preventing diseases and promoting healthy lifestyles (in tandem with diagnosis and treatment) is the best way to make Americans healthier. Seven in 10 want the United States to invest more in disease prevention and healthy living.25 EMERGING THREATS TO PUBLIC HEALTH Unfortunately, public support also faces looming threats. These include global climate change, population shifts, emerging infectious diseases, and growing concern over water and food security. Public health is handicapped by outdated and vulnerable technologies, antiquated lab capacity, a workforce in need of training and reinforcements, and inadequate emergency preparedness. The IOM reviewed the needs of public health and recommended steps to strengthen public health infrastructure, build partnerships, develop systems of accountability, emphasize evidence, and improve communication.26 Is there a role for EM? Absolutely. Several years ago, former CDC Director Jeffrey Koplan gave the keynote address at my department’s annual retreat. He began his remarks by stretching his arms widely. ‘‘Many people wonder what public health and emergency medicine have to offer each other,’’ he said. ‘‘On one hand (he wiggled his left), public health focuses on prevention and wellness, while emergency medicine (right hand now), focuses on ‘resurrection medicine.’ But in fact, the relationship between the two is more like this.’’ And with that, he raised both hands above his head to form a circle. SHARED TRAITS BETWEEN EM AND PUBLIC HEALTH Emergency medicine and public health share several attributes in common. Both disciplines think about the health of populations as well as individuals. EPs and nurses see what happens when public health fails. We are often the first to spot events of public health importance, such as an outbreak of infectious disease. And we, like our public health colleagues, regularly deal with vulnerable patients and populations. But there are formidable obstacles to achieving closer integration. The cultures of public health and EM are very different. We are action-oriented; they are more analytical. The two disciplines use different measures of performance. Adopting new roles can threaten the status quo in both camps. And of course, combining two underresourced and undervalued disciplines does not help either one get a bigger budget! On a practical level, there is a dearth of cross training—although there are probably more MD ⁄ MPH grads in EM than ever before. Most public health officials know relatively little about emergency medical services (EMS) and emergency care. Our disciplines have few opportunities to share ideas. Both groups face overwhelming needs in their respective domains.

Kellermann

•

AEM CONSENSUS CONFERENCE KEYNOTE ADDRESS

These barriers can be overcome. First, we need to build bridges by forging partnerships with community partners, including public health agencies, community nonprofits, and other nonprofits. Second, we need to create infrastructure to promote effective communication and cooperation. Third, we need to develop or acquire new tools to facilitate innovation, and fourth, we need to find champions to advance our cause. We already have two of the best: Linda Degutis, an Associate Professor in the Yale Department of Emergency Medicine, is the Immediate Past President of the American Public Health Association (APHA). Georges Benjamin, a longtime EP, is the APHA’s Executive Director. Generally speaking, EPs can advance public health at three levels: ‘‘retail,’’ ‘‘wholesale,’’ and ‘‘grand scale.’’ ‘‘Retail-level’’ interventions are based on the realization that one ED encounter often presages others and the idea that timely interventions delivered in the ED may prevent subsequent problems that bring the patient back for additional treatment or produce needless morbidity or mortality. The most obvious historic example is immunization for tetanus, a practice widely accepted as a responsibility of EPs. But if tetanus, a disease that killed 28 people in the United States in 2007,27 is worth preventing, what about influenza, pneumococcal sepsis, respiratory failure, and other conditions that kills thousands or tens of thousands? I am not proposing that we usurp a traditional role of primary care, but all of us see patients who have little or no access to care outside the ED. Doesn’t it make sense to catch them while we can, rather than wait for one to return with sepsis or respiratory failure months or even years later? Other examples of ‘‘retail’’ interventions include screening, brief intervention, and referral to treatment (SBIRT) programs for alcohol and drug abuse,28 smoking cessation (the ED visit as a ‘‘teachable moment’’),29 screening and referral of victims of intimate partner violence,30 and enlisting EMS to promote injury prevention.31 ‘‘Wholesale’’ interventions take the idea a step farther, to the level of neighborhoods or communities. Examples include geographic information systems analysis of 9-1-1 and ⁄ or EMS data to identify ‘‘hot spots’’ of violence and ‘‘hot dot’’ locations for vehicular or car–pedestrian collisions, emergency-preparedness activities, neighborhood-based cardiopulmonary resuscitation training, and public education through interviews with the local press. ‘‘Grand-scale’’ interventions expand the frame to the level of a state, the nation, or even the world. I base the term on an aphorism attributed to Rudolf Virchow, who reportedly said, ‘‘Medicine is a social science, and politics nothing but medicine on a grand scale.’’32 Examples of grand-scale interventions include EM advocacy for such worthwhile policies as primary enforcement of seatbelt laws, ‘‘all-rider’’ motorcycle helmet laws, and graduated driver’s licensing. Funding for trauma care networks and injury control programs does not happen spontaneously, but as a result of persuasion. Excise taxes on tobacco and alcohol are a useful source of revenue; more important, they discourage underage smoking and drinking. Work with national and international organizations such as the APHA,

ACAD EMERG MED • November 2009, Vol. 16, No. 11

•

www.aemj.org

CDC, the Pan American Health Association, and WHO can make a big difference. Numerous examples abound within the Emory Department of Emergency Medicine, now led by my successor, Dr. Kate Heilpern. In fact, we have modeled our entire department on the synergy between EM and public health.33 Examples include: • The SAFETY (Supporting African American Families, Empowering Their Youth) and NIA projects, which are aimed at identifying and assisting victims of intimate partner violence. • A CDC-funded project to promote human immunodeficiency virus screening in Emory-affiliated EDs. • The Brief Alcohol Screening and Intervention for College Students (BASICS)—a Substance Abuse and Mental Health Services Administration-funded program to promote SBIRT with trauma victims treated in Georgia hospitals. • ‘‘Cops and Docs’’—a collaborative effort that contributed, over a 10-year period, to a striking and sustained decline in Atlanta’s homicide rate. • The Emory Center for Critical Event Preparedness and Response—a university-funded effort to promote all-hazards preparedness within Emory University, Emory Healthcare, and the communities both organizations serve. • The Emory Center for Injury Control—a long-standing interdisciplinary program that seeks to reduce death, disability, and costs due to injuries. The Center’s director, Dr. Deb Houry, recently secured a major grant from the CDC’s National Center for Injury Prevention and Control to make it a CDCfunded Injury Control Research Center (ICRC). • Georgia’s teenaged and adult driver responsibility act (TADRA), a legislative package that combined graduated driver’s licensing with tough-love provisions to discourage teen DUI, speeding, and reckless driving. Colleagues and I found that this law had a dramatic and sustained effect on reducing fatal crashes involving 16- and 17-year-old drivers in Georgia.34 It could be a model for the nation. • The Cardiac Arrest Registry to Enhance Survival (CARES), a CDC-funded program to enable communities of any size to identify, map, and document the outcomes of episodes of out-of-hospital cardiac arrest. The data can be used to pinpoint opportunities to improve EMS performance at the community level. • Global Health—with funding provided by the National Institutes of Health’s Fogarty International Center, Emory EM faculty are training a cadre of trauma and injury control researchers from the Republic of Mozambique. In the forward to Case Studies in Emergency Medicine and Public Health,35 Dr. Foege described the budding relationship between the fields. His words resonate as powerfully today as they did in 1996: Never again will one person be able to encompass all knowledge. Specialization is necessary; important for practitioners, essential for the care of a patient, and crucial in the development of an area of new knowledge or expertise. But with

1063

specialization comes new interdependence. The best specialists have broad vision. They see where their skills fit in; they retain an interest in the global view; and they benefit from exposure to other perspectives, problems, and talents. Two decades ago, the juxtaposition of emergency medicine and public health would have seemed unreasonable. Now it is an obvious match. In the time-pressured world in which EM is practiced, can we maintain Dr. Foege’s ‘‘global view’’? Can we leverage our broad-based skills, the populationbased perspective that naturally stems from our clinical practice, and our commitment to help others to advance public health? Over the course of this conference, you will explore, discuss, and debate these questions. But for me, the answer is obvious. Yes we can, because you do it every day. References 1. Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health System. Hospital Based Emergency Care: At the Breaking Point. Washington, DC. The National Academies Press, 2006. 2. Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006; 355:1300–3. 3. United States Government Accountability Office. Emergency Departments: Crowding Continues to Occur, and Some Patients Wait Longer than Recommended Time Frames. Report to the Chairman, Committee on Finance, U.S. Senate. 2009. Available at: http://www.gao.gov/new.items/d09347.pdf. Accessed Aug 2009. 4. Hoot NR, Aronsky DA. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008; 52:126–36. 5. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among U.S. emergency departments. Ann Emerg Med. 2006; 47:317–26. 6. Johnson L, Taylor T, Lev R. The emergency department on-call backup crisis: finding remedies for a serious public health problem. Ann Emerg Med. 2001; 37:495–9. 7. Institute of Medicine, Committee on the Consequence of Uninsurance. Insuring America’s Health. Washington, DC: The National Academies Press, 2004. 8. Institute of Medicine, Committee on the Consequences of Uninsurance. Coverage Matters: Insurance and Health Care. Washington, DC: The National Academies Press, 2002. 9. Dorn S, Garret B, Holahan J, Williams A. Medicaid, SCHIP, and Economic Downturn: Policy Challenges and Policy Responses. Washington, DC. The Kaiser Commission on Medicaid and the Uninsured. April 2008. Available at: http://www.kff.org/medicaid/ upload/7770.pdf. Accessed Aug 17, 2009. 10. The New York Times. May 4, 2008. The Mounting Burden for Health Care (graphic). Available at: http://www.nytimes.com/imagepages/2008/05/04/

1064

11.

12.

13.

14. 15.

16.

17.

18.

19.

20.

21. 22.

23.

Kellermann

business/20080504_INSURE_GRAPHIC.html. Accessed Aug 17, 2009. Commonwealth Fund Commission on a High Performance Health System. Why Not the Best? New York, NY: The Commonwealth Fund, July 2008. Available at: http://www.commonwealthfund.org. Accessed Aug 17, 2009. Connolly C. U.S firms losing health care battle, GM chairman says. Washington Post. Feb 11, 2005. p E01. Available at: http://www.washingtonpost.com/ ac2/wp-dyn/A15828-2005Feb10?language=printer. Accessed Aug 17, 2009. Rowland D, Hoffman C, McGinn-Shapiro M. Health Care and the Middle Class: More Costs and Less Coverage. Menlo Park, CA. The Henry J. Kaiser Family Foundation. July 2009. Publication #7951. Available at: http://www.kff.org/healthreform/upload/ 7951.pdf. Accessed Aug 17, 2009. Kitzhaber JA. Creating a New Health System. Portland, OR: The Archimedes Movement, 2009. Anderson GF, Frogner BK. Health spending in OECD countries: obtaining value per dollar. Health Aff. 2008; 27:1718–27. U.S Congress. The Long-term Outlook for Health Care Spending: A CBO Study. Washington, DC. Congress of the United States, Congressional Budget Office, November, 2007. World Health Organization. The World Health Report 2000 – Health Systems: Improving Performance. Geneva, Switzerland: WHO, 2000. Nolte E, McKee CM. Measuring the health of nations: updating an earlier analysis. Health Aff. 2008; 27:58–71. Institute of Medicine, Committee on Health Insurance Status and Its Consequences. America’s Uninsured Crisis: Consequences for Health and Health Care. Washington, DC: The National Academies Press, 2009. Institute of Medicine, Committee on the Consequence of Uninsurance. A Shared Destiny: Community Effects of Uninsurance. Washington, DC: The National Academies Press, 2003. Spivey M, Kellermann AL. Rescuing the safety net. N Engl J Med. 2009; 360:2598–601. Orzag P. The long-term outlook for health care spending. Congressional Budget Office presentation, November 13, 2007. Available at: http:// www.cbo.gov/ftpdocs/87xx/doc8758/11-13-LT-Health. pdf. Accessed Aug 23, 2009. Foege WH. Redefining public health. J Law Med Ethics. 2004; 32(s4):23–6. http://www3.interscience.

24.

25.

26.

27.

28.

29.

30.

31.

32. 33.

34.

35.

•

AEM CONSENSUS CONFERENCE KEYNOTE ADDRESS

wiley.com/journal/119191698/abstract/. Accessed May 18, 2009. Institute of Medicine Committee on Capitalizing on Social Science and Behavioral Research to Improve the Public’s Health. Smedley BD, Syme SL (eds). Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, DC: The National Academies Press, 2002. Quinlan A, Egelsky M. Making Healthy Americans a Priority in 2008. Washington DC, Greenberg Quinlan Rosner Research. January 28, 2008. Available at: http://healthyamericans.org/reports/files/ BudgetPoll0208.pdf. Accessed Aug 17, 2009. Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public’s Health in the 21st Century. Washington DC: The National Academies Press, 2002. Centers for Disease Control and Prevention (CDC). Summary of Notifiable Diseases–United States, 2007. MMWR Morb Mortal Wkly Rep. 2009; 56:23. The Academic ED SBIRT Research Collaborative. The impact of screening, brief intervention and referral for treatment (SBIRT) on emergency department patients’ alcohol use. Ann Emerg Med. 2007; 50:699–710. Bernstein SL, Boudreaux ED, Cydulka RK, et al. Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations (executive summary). Ann Emerg Med. 2006; 48:417–25. Houry D, Kaslow NJ, Kemball RS, et al. Does screening in the emergency department hurt or help victims of intimate partner violence? Ann Emerg Med. 2008; 51:433–42. Yancey AH, Martinez R, Kellermann AL. Injury prevention and emergency medical services: the ‘‘Accidents Aren’t Program.’’ Prehosp Emerg Care. 2002; 6:204–9. Eisenberg L. Rudolf Virchow: the physician as politician. Med War. 1986; 2:243–50. Wenger DC. An emergency medicine department for the 21st Century. Acad Phys Sci, 2004. Available at: http://www.acphysci.com/aps/resources/PDFs/ Jun04_feature.pdf. Accessed Aug 23, 2009. Rios A, Wald M, Nelson SR, Dark KJ, Price ME, Kellermann AL. Impact of Georgia’s Teenage and Adult Driver Responsibility Act. Ann Emerg Med. 2006; 47:361–9. Foege W. Foreword. In: Bernstein E, Bernstein J (eds). Case Studies in Emergency Medicine and Public Health. Boston, MA: Jones and Bartlett, 1996.