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A California study shows that clinicians need to educate HIV-infected patients about when to contact their physicians instead of automatically going to the emergency room when faced with a health crisis. Patients often will use the emergency department instead of visiting their regular doctor, even for common symptoms such as tension headaches, concludes the study, which was published in the December 2000 issue of the Journal of General Internal Medicine.1
"I thought the findings were moderately surprising," says Allen L. Gifford, MD, assistant professor of medicine at the University of California in San Diego. Gifford was the lead investigator of the study, which involved the VA San Diego Healthcare System in San Diego and the University of California San Diego School of Medicine in La Jolla.
Researchers initially wanted to study what HIV patients did when they were experiencing common HIV symptoms, both serious and minor. Their concern was that patients might tend to ignore the symptoms that could worsen and lead to more severe — and costly — problems. "The good news is, people didn’t tend to do that," Gifford says. "If they had important symptoms, they’d go right in and get seen."
However, rather than call their physician and seek an appointment, many patients went to the emergency department, and this may be a problem for both economic and clinical reasons. "As a primary care physician myself, I am concerned that over and above the cost issue, patients who get a large part of their care in the ER may in some cases get poorer care because the continuity of care is disrupted," Gifford says. "A lot of times, the information about their care doesn’t get back to their doctors, and sometimes medications are changed."
There could be a variety of explanations for this type of behavior. One reason might be that patients perceive seeing their primary care physician as being less convenient, even if they visit the ER during daytime hours, Gifford says. "Maybe the physician would make them wait longer, or it’d be more complex to wait there, and this is a big factor for people with kids or who work," Gifford explains. "Even if they recognize that they could be seen by their primary care physician, they’d have to take off work to do so, and the ER is open at night."
Another explanation could be that patients did not believe their HIV physician was experienced in handling their more serious HIV symptoms, such as pneumonia, but factors relating to access probably were the main cause for excessive ER use, Gifford says. "HIV providers need to see if they can open up for more hours, particularly as HIV disease tends to become more of a continuous chronic illness with lots of people in the workplace," Gifford says. "This is an issue in health care for women with children and for all kinds of people in the work force."
The study found no differences by gender, but investigators did find consistent differences with regard to socioeconomic factors, such as income level. Also, investigators found that African-Americans had a higher propensity to seek their care in the ER than whites or people of other races, Gifford says.
"We need to find out what’s going on here," Gifford says. "One of the major speculations raised in editorials is whether this is a bit of a cultural phenomenon in the sense that in some African-American communities, perhaps due to years of interacting with health care systems, the habits and culture of how to interact with health care providers have led to a tendency to use the ER in this way." The behavior continues even when educational and economic factors are accounted for, he adds.
Other factors contributing to a patient’s overuse of the emergency room were poverty and higher levels of depression and stress.
Basically, the study highlights the need for HIV physicians to be aware that this could be a problem. They might educate patients about what steps to take in the event that they experience various HIV symptoms, Gifford says. The education needs to be specific to that provider’s circumstances and include detailed information, and it should be presented in clear language with reading-level appropriate sentences if it is written down, he adds.
"Secondly, we need to look at how primary care practices are set up for patients, as well as the structural factors, including the hours of providing care," Gifford says. If an HIV doctor does not see patients after 5 p.m., then it might be appropriate to provide on-call contact numbers or a nurse line to the patient and educate patients on how to use those services.
Another potential solution is for HIV physicians to direct patients to use urgent care centers, which ideally would be associated in some way with the HIV clinic instead of the hospital emergency department, Gifford says. "That’s good only if you have good communication between the primary care doctors and the urgent care center," he adds.
Here are a few details about the study:
• Investigators interviewed more than 2,800 HIV-infected patients between January 1996 and April 1997 about how they would seek care for key HIV-associated symptom complexes.
• Most patients (78%-87%) with advanced HIV disease who were experiencing symptoms said they would seek care immediately from an emergency department or from a primary care provider.
• Symptom scenario questions included: "Suppose you began to have difficulty breathing and had a cough with fever. What would you do?" and "Suppose you had a headache with pressure behind the eyes and nose. What would you do?"
• Investigators determined a patient’s propensity to use the emergency department by summing the number of "go to the emergency room" responses across the three symptom scenarios, using categories of low if they would not go to the ER for any of the clinical scenarios, medium if they would go to the ER for one scenario, and high if they would go to the ER for two or three scenarios.
• Percentages of early HIV disease patients who said they would first go to the ER according to various symptoms were as follows: 42% would go to the ER if experiencing respiratory symptoms with fever; 18% would go the ER if they had a headache behind the nose and eyes; and 14% would go to the ER if they had oral white patches.
• Percentages of advanced HIV disease patients who said they would first go to the ER according to various symptoms were as follows: 45% if they had respiratory symptoms with fever; 25% if they had a headache with stiff neck; 29% if they had a loss of vision.
1. Gifford AL, et al. Propensity of HIV patients to seek urgent and emergent care. Journal of General Internal Medicine 2000; 15:833-840.