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Study: Telemedicine could reduce pediatric ED visits
Docs remain skeptical, say most visits are necessary
Telemedicine has long been recognized for improving access to care as well as access to specialist expertise, particularly in rural facilities. Now, in an unpublished study just completed in Rochester, NY, the lead author says it also can offer a possible solution to overcrowding when it comes to pediatric ED patients, many of whom, he asserts, easily could be treated by a primary care physician.
The report, which has not yet been published, analyzed data from 2006 and tracked all pediatric visits to the city's largest ED, at the University of Rochester Medical Center. The researchers then studied more than 6,000 telemedicine visits during the same period. The ED visits were categorized into ailments that always could be managed by telemedicine; those that were usually treated through telemedicine; and conditions that usually could not be treated with telemedicine. Results showed that nearly 30% of ED visits fell into the first category and could always be treated with telemedicine. If those problems had all been handled through telemedicine, the research concludes, Rochester would have had at least 12,000 fewer pediatric ED visits in 2006.
Many, if not most, pediatric-age ED visits are for nonemergency problems, says Kenneth McConnochie, MD, MPH, founder of Health-e-Access, the University of Rochester Medical Center telemedicine program that uses the Internet to connect pediatricians with sick children at inner-city child care centers. "There are a number of studies showing that between 25% and 75% of ED visits for kids are nonemergency visits," he notes. "If you accept that as a bad thing, it's a crazy use of resources."
EDs have to be prepared to manage the most severe illness and injury episodes, McConnochie says. "They are set up to manage that, and they do it very well," he says.
Subacute visits, he adds, take precious time away from the ED staff, McConnochie says. "The average time to treat a sore throat, ear infection, or pinkeye, is about 4.5 to six hours, according to what parents told us, and sometimes as long as 16 hours," he says. "We can do it in a telemedicine site in no time."
Drilling further down into his study's statistics, McConnochie says that for kids with telemedicine available in their day care center or elementary school, ED use dropped 22% based on a matched comparison of age, gender, socioeconomic status, and season of the year. "For every telemedicine child, they matched them month for month with children of the same age, gender, zip code, and so forth, who did not have access to telemedicine," he says. ED use was down 22%, McConnochie says. "That's good for payers, good for society, and ultimately good for the industry," he says.
But not everyone draws the same conclusions. "Telemedicine will do little to relieve pediatric ED overcrowding," claims Gregory P. Conners, MD, MPH, MBA, professor and interim chair, emergency medicine, University of Rochester Medical Center. "Telemedicine is most appropriate for minor visits, which we can usually manage in the ED fairly efficiently." Overcrowding comes from requiring EDs to manage inpatients or from receiving multiple simultaneously very sick patients, he says.
Ironically, Conners has collaborated with McConnochie on earlier studies and believes in the ability of telemedicine to deliver quality care.
"We took kids who were sick and came for visits and examined them twice — once in person, and once by telemedicine," he recalls. "We found very good agreement between the in-person exam and the telemedicine; the care was just as good."1,2
But quality is not the issue in contention, Conners maintains. What he disputes is the fact that many pediatric ED visits are unnecessary "We in Rochester have great pediatric primary care, and yet we still get a certain number of children each day who come to the pediatric ED because of pinkeye or the equivalent, especially outside of the usual Monday-Friday daytime," he says. "As research in Rochester and other places has shown, if you ask parents why they brought the child to the ED, they often will tell you they were directed there, either by someone representing their primary care office — often a nurse or someone else in the office, sometimes following a written protocol — or a well-intentioned family member or neighbor."
Alternatively, he adds, parents often are unable to get to the doctor's office because there were no short-notice visits available, or they were at work or otherwise unable to get in during the limited hours offered by many primary care practices.