The emergency department: middle-man for pediatric referrals

By Christopher Walsh, medwireNews Reporter

Specialists are more willing to see publicly insured pediatric patients if they are referred from an emergency department (ED) rather than directly from a primary care physician, according to research findings from the USA.

Consequently, primary care physicians often use this "middle-man" approach as a "work-around" to overcome the barriers they face in ensuring that children receive specialty care, say the authors

The investigators interviewed a nonrandom sample of 40 specialists and primary care physicians in Cook County, Illinois, from April to September 2009. They designed a qualitative questionnaire with open-ended questions about obtaining outpatient specialty care for children insured with Medicaid or through the Children's Health Insurance Program (CHIP).

Among the 14 primary care physician respondents, 11 (79%) said they encountered limitations to accessing specialty appointments for Medicaid-enrolled patients distinct from those encountered with their commercially insured patients.

A total of 26 specialists were questioned. Of the 18 specialists who practiced predominantly in an outpatient setting, 13 (72%) said that they rationed their appointments depending on insurance status. The authors suggest that these decisions were probably influenced by economic strains or direct pressure from their institutions.

Nevertheless, specialists described an "obligation" to see patients referred from the ED, "even if their practice did not otherwise accept public insurance and even if they considered the complaint nonurgent."

Responses to the questionnaire revealed various other factors that may encourage specialists to accept patients with Medicaid/CHIP, including the following: high acuity or complexity of the presenting disease itself; cases of patient hardship; geographic proximity; an informal economic relationship with the referring primary care practice; personal requests from primary care physicians; or institutional affiliations with the referring ED or primary care practice.

"EDs have the potential to play a role in improving care coordination and access to outpatient specialty care," say lead author Karin Rhodes (University of Pennsylvania, Philadelphia, USA) and colleagues in the Annals of Emergency Medicine.

However, they caution that their findings "do not imply that the ED is a solution to the access limitations faced by publicly insured patients."

Rather, they suggest that the established, underlying mechanisms that facilitate the equitable distribution of ED-referred patients across specialist providers could be translated to the outpatient setting.

Such strategies, which are not often in place to handle outpatients referred from primary care physicians, increase the likelihood that ED-referred patients will successfully obtain an appointment with a specialist, they conclude.

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