Original Contribution
The worsening of ED on-call coverage in California: 6-year trend

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Abstract

To reassess problems with on-call physician coverage in California, we repeated our anonymous 2000 survey of the California chapter of the American College of Emergency Physicians. Physicians responded from 77.4% of California emergency departments (EDs), 51.0% of ED directors, and 34% of those surveyed. Of 21 specialties, on-call availability worsened since 2000 for 9, was unchanged for 11, and improved for 1. Of ED directors, 54% report medical staff rules require on-call duty, down from 72% in 2000. Hospitals have increased specialist on-call payments (from 21% to 35%, with 75% paying at least one specialty). Most emergency physicians (80.3%) report insurance status negatively affects on-call physician responsiveness, up from 42% in 2000. Emergency departments with predominately minority or uninsured patients had fewer specialists and more trouble accessing them. Insurance status has a major negative effect on ED consultation and follow-up care. The on-call situation in California has worsened substantially in 6 years.

Introduction

The nation's emergency departments (EDs) are a safety net for patients who lack primary physicians. Specialty care is often even more difficult to access. The 1986 Emergency Medical Transfer and Active Labor Act (EMTALA) and its modifications mandate that all patients who present to an ED must undergo a medical screening examination to determine the presence or absence of a medical emergency. Furthermore, the statute mandates that on-call physicians respond at the request of the emergency physician (EP). Failure to comply carries a civil penalty up to $50 000 per violation to the physician and hospital, as well as loss of Medicare and Medicaid revenue.

California is symptomatic of a larger, nationwide, problem. The early growth of managed care, coupled with growth in underinsured immigrants, has made access to care among the worst of the states [1]. From 1990 to 2001, the number of California hospital EDs declined by 11.3% (405–359), with further decline to 345 EDs documented by the California Office of Statewide Health Planning and Development in 2006, reflecting an aggregate 14.8% decline over 16 years [2], [3]. During approximately the same time period, the National Ambulatory Medical Care Survey documented that ED patient visits increased 27.8% from 90 million in 1992 to 115 million in 2005 over 13 years [4]. Despite compensatory increases in the number of beds per remaining ED, nurse staffing ratios and inpatient capacity constrain ED operations [5].

California EPs perceive a crisis of on-call specialists to consult in the ED, admit patients, or provide follow-up care [6], [7]. Anecdotally, EMTALA may make specialists reluctant to serve on the ED call panel, as mandatory reporting provisions obligate them to respond. Our 2000 survey showed that community hospitals lack the mandated call panels common to university, county, and managed care hospitals [8]. One strategy to remedy the on-call problem is to pay specialists. As the number of California's uninsured and underinsured grows, and hospital operating margins tighten, this problem worsens.

To determine more recent trends in 2006, we repeated the survey. We sought to determine the state of on-call response for California EDs, by specialty, and compare to 2000, across different types of hospitals (university, community, county, and health maintenance organization [HMO]), and at night and on weekends. In addition, we sought to validate the relationship between payer type, insurance status, and ethnicity and availability of on-call specialists, which we found in 2000.

Section snippets

Methods

In March through May 2006, we emailed and then mailed an anonymous survey to all nonresident physician members (n = 1646) of the California Chapter of the American College of Emergency Physicians (ACEP). Beyond this, we made no attempt to survey nonresponders. This survey was nearly identical to one sent out in 2000 [8].

The survey asked:

  • 1.

    ED patient ethnic and payer mix, and volume.

  • 2.

    Type of ED practice (HMO, county, university, or community).

  • 3.

    Which of 21 specialties listed were on the ED call

Results

We received responses from 77.4% (267/345) of hospital EDs, 51.0% (176/345) of ED directors, and 33.8% (557/1646) of EPs. These were not statistically different from the response rates from the 2000 survey.

Of our 557 individual responses, 113 (20.2%) came by email, and 444 (79.8%), by mail. We received responses from 267 hospitals, 16 county (6.0%) , 17 university (6.4%), 20 HMO (7.5%) and 209 community hospitals (72.3%). Responding EDs reported an average patient census of 41 712/year,

Discussion

Nearly 315 000 Americans seek care in the nation's EDs each day, 10% of these in California. Nationwide, the ED visit rate has increased 7% in the past decade, from 36.9 to 39.6 per 100 people per year [9]. Although the number of California EDs decreased by 11.3% in the 1990s, there was a significant increase of aggregate patient volume for private hospitals of 512 patients per year, with a converse decrease of 1085 in public hospitals [10]. We found that community hospitals had more problems

Limitations

As with all surveys, responses are subject to recall bias. EP impressions may not reflect reality, as other practice stresses such as ED crowding may alter the tenor of responses to on-call questions. We did not survey nonresponders. Our 34% overall response rate was low.

We averaged multiple EP responses from one site and report them as a single-site response. However, this potentially allows a single respondent's opinion to misrepresent the true scope of the problem in a given hospital.

Summary

Our data show a worsening on-call crisis in California over the past 6 years. This problem is not confined to lower socioeconomic, inner-city areas but, rather, most acute in urban and suburban community hospitals. A predominately minority or underfunded clientele makes on-call response even more problematic.

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    Presented at the 4th Mediterranean Emergency Medicine Congress, Sorrento, Italy, September 2007, and Society of Academic Emergency Medicine, Annual Meeting, Washington, DC, May 2008.

    Source of funding: internal department funds.

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