International Journal for Quality in Health Care 14:149-153 (2002)
© 2002 International Society for Quality in Health Care
Patient compliance with managed care emergency department referral: an orthopaedic view
1Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles
2Department of Orthopaedic Surgery, Kaiser Permanente Southern California, Bellflower
3Center for Health Policy Research, University of California, Los Angeles, CA, USA
Address reprints requests to Don Saroff PO Box 910 Derby Line Vermont 05830-0910 USA. E-mail: donsaroff{at}earthlink.net
Objective. Patient compliance with emergency department (ED) generated referral is an important part of the delivery of quality health care. Although many studies from non-managed care health centers have reported on ED patient compliance, no studies have reported on this in a managed care setting. The objective of this study is to examine patient compliance with ED-generated referral and to produce a benchmark of follow-up rates possible in a capitated managed care system. That is to say, in a health care system whose members pay a uniform per capita payment or fee, one that has salaried physicians, owns its own hospitals, and has a mechanism of transition from ED to outpatient clinic that ensures referral accessibility.
Design. Retrospective review of consecutive ED patient compliance with ED-generated referral.
Patients/methods. All consecutive patients who presented to a managed care hospital’s ED with an acute fracture and who were given an outpatient referral during the period from 23rd December 1998 to 23rd January, 1999. Of 8000 consecutive ED patients, 234 were included in the study. Compliance with ED-generated referral was determined from outpatient clinic records.
Results. Of the 234 patients treated in the ED and referred, 222 (94.9%) complied with follow-up appointments.
Conclusions. We have demonstrated that an ED patient follow-up compliance rate of 94.9% can be obtained. It is probable that the high compliance rate is due to the features of the system studied. The high rate may also be related to the specific diagnosis studied, although previous literature reports poor ED patient compliance for the same diagnosis in a different ED setting. Additional research is needed to determine whether the high compliance rate reported in this study can be obtained in ED settings that are not part of a similar managed care system and to determine the role of referral accessibility (or inaccessibility) in current ED settings.
Keywords: access, compliance, emergency department, fracture
Compliance with follow-up appointments generated in EDs is an important part of the delivery of quality health care[1–3]. This is especially true for most patients with acute fractures. Only one small study has examined whether patients with an acute fracture who are referred for follow-up to be managed as an outpatient obtain that visit [4]. While one might expect patients with acute fractures to comply with follow-up care, in a study published in the American Journal of Emergency Medicine, only 19 of 30 (63.3%) kept the follow up-appointment [4].
Other studies also address, in general, whether ED patients obtain their follow-up appointments [5–8]. The results of these indicate poor compliance rates (as in the small fracture study). One study reported an overall ED compliance rate of 28%, which included a ‘non-urgent’ condition compliance rate of 34%, and a ‘referrals to internists’ compliance rate of 17% [4]. Another study evaluating ‘short-term’ compliance reported a 68% compliance rate [8]. Patient demographics such as age, diagnosis, and socioeconomic status have been cited as reasons why patients do not obtain their ED-generated follow-up appointments [9–16]. Solutions to the compliance problem have targeted patients within ‘risk’ groups and have included patient education and improved methods of ‘giving’ the referral—such as writing down instructions [4, 7, 17–19].
The previous studies, however, were conducted prior to managed care reform or were conducted in non-managed care affiliated EDs. The studies paid little attention to provider or system characteristics—variables that may also influence ED compliance rates. Variables such as whether the ED gives referrals that are actually accessible to patients have not been studied, even though a 1999 publication [8] mentioned that inability to obtain an appointment was cited by over one-third of those who did not comply with follow-up care as instructed. Within certain current managed care systems, some of the limitations of the previous studies—such as determining whether or not ED-generated referrals are truly accessible—are theoretically minimized. A study of ED patient compliance within a managed care system that ‘ensures’ access may shift the ‘classic’ focus of compliance responsibility away from individual patient demographics and toward system or provider characteristics.
The goal of this study was to evaluate the efficacy of ED patient referral and to answer the question of whether it is possible to provide follow-up care for those patients with acute fractures in one managed care system. Fractures are notably ‘obvious’ conditions, but the literature reports poor ED follow-up compliance in cases with this diagnosis, and poor ED follow-up compliance (47%) with other ‘obvious’ diagnoses such as lacerations [4]. The managed care ED system used in this study has the following characteristics: salaried physicians, capitation (a payment system in which each patient or member pays a uniform membership fee), owns its own hospitals, and a referral mechanism that ensures accessibility. In the particular system studied, there are no incentives in place for compliance, and there are no disincentives in place for non-compliance. Since the current health care environment has changed since the majority of the previous studies were conducted, one purpose of this study is to benchmark what it is currently possible to achieve. Similar ‘quality benchmarking’ studies concerning other medical conditions and systems have been published by Brook [20].
There is no specific control group in this study other than, in a very limited view, the previous work. Therefore, this study does not attempt to compare two different settings. It simply reports the quality within one setting and explores ED patient non-compliance as a dysfunctional system issue and not as a patient-centered deficiency.
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Methods |
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The study was conducted at a metropolitan area ED (approximately98 000 annual ED visits). The ED is part of a ‘staff model’ managed health system, which charges uniform fees per patient, owns its own hospitals, has salaried physicians, and has a mechanism of transition from ED to outpatient clinic that ensures referral accessibility. The specific name of the system is Kaiser Permanente of Southern California, and the system owns numerous hospitals in Southern California, of which the specific hospital used in this study—Kaiser Bellflower hospital located in Bellflower, California—is one. Within the Bellflower hospital there is no incentive in place for compliance, and there is no disincentive in place for non-compliance. Kaiser Permanente of Southern California is one branch in the Kaiser Permanente Health System ‘tree’, and there is also a Kaiser Permanente of Northern California and other Kaiser Permanente branches located elsewhere in the US. Those patients enrolled within the Kaiser Permanente Health System are often referred to as Kaiser Permanente ‘members’. The total number of Kaiser Permanente members within the United States approaches nine million.
The population of this study consisted of all patients presenting consecutively to Kaiser Bellflower hospital’s ED from 23rd December 1998 to 23rd January 1999. All patient records were reviewed and all fractures were identified by either review of the X-ray, X-ray report, or medical record. Patients admitted to the hospital directly from the ED and patients definitively treated in the ED and not given a follow-up appointment were excluded. For patients with a fracture who were given a referral, clinic records were then matched to ED records to record compliance with follow-up appointments.
The mechanism of transition from the ED to the outpatient clinic was as follows: patients with acute fractures were given a discharge slip from the ED. The ED slip contained written instructions with both the location and telephone number of the outpatient clinic and a time-frame for suggested follow up. A separate piece of paper containing referral authorization (the actual referral slip) was also given to the patient. Referred patients were not given priority at the clinic, but a referred patient is ensured access to the clinic on any given day. For example, the front personnel at the clinic cannot tell a referred patient that there is no available time that day, or that the patient cannot be seen that day. Any non-plan member patients seen in the ED and paying for that visit have similar access to the clinic. All data on the patients seen in the orthopedic clinic are entered into an electronic medical record developed by one of the authors (RD).
Data collection also included patient demographics, specifically age—pediatric (0–12 years), young adult (12–40 years), and older adults (over 40 years)—gender, and insurance status: a member of the Kaiser Permanente Health Plan, California Medicaid insurance, no insurance, or any insurance other than those mentioned above.
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Results |
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There were 8342 visits to the ED during the one-month study period. Among these visits, we identified 290 patients who had a fracture (3.5%). Nineteen of these patients were admitted directly from the ED; 37 were definitively treated in the ED and not referred; 234 patients were treated in the ED and referred (of these, 222 patients [94.9%] complied with the appointment; Table 1).
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Of the referred patients, 58% were male and 42% were female, 36.3% were pediatric patients, 34.2% were young adults, and 29.5% were older adults. Five percent of the patients were California Medicaid recipients or had other types of insurance, and 95% were members of the Kaiser Permanente health system. Of the 12 patients who were not compliant with the ED referral, two had California Medicaid or other insurance coverage (16.6%) and ten were Kaiser Permanente health system members (83.4%). Nine of these patients were male (75%) and three were female (25%); four were pediatric patients (33.3%), seven were young adults (58.3%), and one was an older adult (8.3%) (Table 2).
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Discussion |
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Patient compliance with ED-generated referral is an important aspect of the delivery of quality health care. Previous studies have addressed ED patient compliance and, in general, reported poor compliance rates (Table 3).
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In past studies, patient demographics have been cited to explain poor compliance. The age of the patient, the gender of the patient, the urgency of the complaint (diagnosis), and the patient’s socioeconomic status are all discussed as reasons for poor patient compliance. Interventions to correct poor compliance have focused on demographically identified ‘risk’ groups and have included motivational techniques, education, telephone contact, and written instructions [21]. Some authors do acknowledge potential compliance difficulties relating to transportation, child care, cost and inaccessibility, as opposed to patient lack of understanding or patient denial of disease [8, 17, 22]. Acknowledgment of the above difficulties begins to implicate health system characteristics as potential contributors to poor compliance.
One study from the early 1980s did recognize the importance of the existing health care ‘systems’ of that time, and hypothesized that ED patient compliance could be different between urban teaching hospital clinic systems and non-academic community hospitals [5]. Researchers at a small community hospital in New England excluded patients with fractures and also certain other conditions, but did find higher compliance rates in the population studied than in the previously mentioned fracture study. The study enrolled very few patients and, as a result of differences in the health care environment of that time compared with that of today, results are not generalizable to the current environment. At that time, physicians in private practice actually went to the ED to care for patients, and referrals that would be given in the current environment were not given then.
Although system and provider characteristics are not generally the focus of previous academic ED compliance studies, variables relating to the health system and provider play a large role in patient compliance. One health system or provider variable not tested in previous studies concerns the rate of inaccessibility of referral, even though, as mentioned earlier, inability to obtain an appointment is cited by ‘non-compliant’ patients [8]. In other words, is the patient—due to any provider or health system characteristic—discouraged or unable to obtain the follow-up visit? Identification of such a complex variable in the health system environment prevailing at the time of the previously mentioned studies was very difficult if not impossible. The current health care environment influenced by managed care reform potentially minimizes certain health system variables such as clinic access problems.
In certain managed care systems, as in the one used in this study, the variable of whether the ED gives patients referrals that the patients are ‘unable’ to obtain is theoretically minimized. Within such a system, which maximizes access, a study might reveal that ED compliance is not predominantly a function of patient characteristics but a function of the characteristics of the given health system. The question of ED patient compliance in a system like the one studied here, and the potential for results different from those reported previously, formed the basis for our study.
The ED and specific health system used in this study represent part of a system where access following ED evaluation is controlled. All patients seen in the ED have access to the clinics to which they are referred. This access has two components. The first is that a patient seen in the ED, whether a plan member or otherwise, automatically (if given the referral slip) has the ability to obtain the referral. The second is a specific time issue, in the sense that the front-office personnel at the clinic cannot tell a patient that there is no availability on a given day. Essentially, no one is turned away unless the patient wishes to have an alternativee treatment date. Also, the clinics are contained within the same building complex, or in other hospital building complexes owned by the same health plan, and these may be more convenient geographically for a given patient. Our basic question was whether patients, in an environment that eased the traditional burdens of access, complied with ED referral at a greater rate than that reported in previous studies.
Using fracture care follow up as a representative diagnosis–care path, we found a 94.9% ED compliance rate among 234 patients. This is different from the rate found in the only other fracture compliance study in the literature (63% compliance among 30 patients). However, patient demographics in this current study cannot be ignored, and do represent the major limitation of this study. The vast majority of the patients in this study were insured Kaiser Permanente members and only 5% were non-members, had Medicaid coverage, or were uninsured recipients. Even so, the rate of 94.9% is higher than a community study (in the early 1980s) conducted in the ED in a New England suburban, upper-middle class area that reported an ED patient compliance rate of 83.7% among 55 insured patients with private physicians. That study (mentioned earlier) did not, however, include fracture follow up. Also, there is no true control group, only historical controls from a medical environment that is different from the present environment. As stated earlier, however, the purpose of this study was not to compare different systems or to re-state the demographic information as related to compliance already reported in other literature. This study simply reports the quality of care in one setting and raises the question that system factors along with patient demographics may play a role in compliance.
We have demonstrated that an ED patient follow-up compliance rate of 94.9% can be obtained. This rate is much higher than that previously reported, even for ‘obvious’ and urgent conditions, and sets a benchmark for what is possible in the health care system studied. It is probable that the high compliance rate is due to the features of this capitated managed care system. In such a system, patient characteristics previously thought to be responsible for ED compliance may not be as important as originally thought. The role of system characteristics may greatly influence ED compliance rates. One of the main variables relating to ED compliance may relate to the accessibility of the referral, a variable previously untested and presently optimized in some managed care systems. Additional research is needed in two areas: (1) to determine whether such compliance rates obtained in this study can be obtained in ED settings that are not part of a similar managed care system; and (2) to determine the role of referral accessibility (or inaccessibility) in current ED settings.
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This study was funded by the Robert Wood Johnson Foundation/UCLA Clinical Scholars Program. The views expressed in this paper are solely those of the authors and do not necessarily represent those of the Robert Wood Johnson Foundation.
Accepted for publication November 22, 2001.
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