Primary Care in the Urban ER

For many decades, urban emergency departments (EDs) have served as the safety net by which any person, regardless of means, could access the health care network. Providing primary medical care to indigent populations was an unwritten responsibility usually practiced with the same attention given to emergency and trauma services. In fact, public hospital emergency departments often viewed the Medicaid reimbursements from non-urgent care as the fiscal backbone needed to support more expensive, but sporadic emergency procedures. Recently, however, diminishing reimbursement fees and steadily increasing utilization rates threaten the ability of urban emergency departments to maintain these services for the poor. Financially-disabled hospitals have closed their emergency departments and deferred patients to other institutions which are now forced to administer care in overcrowded, inefficient, and poorly-funded facilities.

• Which population groups receive primary care in emergency departments?
• What are their other health care options?
• What burdens are imposed by providing non-urgent care in the emergency department?
• How can current barriers to primary care be eliminated?

Some policymakers attribute this situation to the "inappropriate use" of expensive ED resources for primary care, suggesting that transferring non-urgent patients to less-costly primary care clinics would alleviate current burdens. Others argue, however, that many of the financial and nonfinancial barriers to these outpatient clinics are still in place, and local hospital EDs are the only accessible option for poor and uninsured patients. Currently, in many urban EDs, patients requiring both urgent and non-urgent care leave without being seen, unable to sit any longer in overcrowded waiting rooms. With more hospital closings predicted, the plight of the urban emergency department will intensify. There is a real danger that the safety net will eventually collapse, and those populations that rely on the emergency department for their care will fall out of the health care system completely.

STUDENT ORGANIZERS GUIDE
This box examines the role of the urban emergency department in providing primary health care to inner-city populations and the overall burden imposed by this responsibility. Included in this box you should find: a student organizers' guide with suggestions for speakers and activities; a brief review of the current literature on the topic; a student handout compiling important facts and data for quick review; a copy of the article, "Primary Care and Public Emergency Department Overcrowding" from the American Journal of Public Health; and a short evaluation form to assess the quality and usefulness of this box.

Activity Suggestions

1. Organize a "brown bag" lunch-time series to discuss the many issues involved in using the emergency room for primary care and possible ways to alleviate the current burden on many urban EDs. This could also be done after class or over dinner. Order pizza if funding allows. Medical students love free pizza!
2. Invite an emergency medicine physician or administrator from a nearby municipal/county hospital to lead a discussion. To find local contacts specializing in this topic, contact Susan Cahn at the American Hospital Association, Society for Ambulatory Care Professionals at (312) 422-3903, or call the American Public Health Association at (202) 789-5600. Also, although this box focuses on the plight of urban emergency departments, many of these issues are relevant for rural hospitals as well. The most important thing is to find a lively speaker who is well-versed in the current debate surrounding non-urgent care in the emergency room.
3. Organize a forum. Have the students and/or professionals act as members of a special committee designated to brainstorm solutions for reducing financial burdens and ED overcrowding. Give all students a handout to familiarize them with the descriptive data. Focus on utilizing the time to resolve the problem rather than reiterate it.
4. Organize a debate. Divide the participants into two groups-one side will argue that using the emergency department for primary care is inappropriate and unnecessarily expensive; the other will argue that the ED is an appropriate environment for primary care and therefore hospitals should be adapted to meet this responsibility. Do not let student participants choose their own group. Often the best way to remain open-minded is to defend an argument you do not support.
5. Observe firsthand. Most schools allow medical students an opportunity to spend a few hours a week observing in the ER. Utilize this time to assist the triage nurse in classifying the urgency of the patients' complaints. Try to make contacts with local public health clinics where patients requiring non-urgent care can receive quality treatment without long waits. It will be necessary to make appointments for the patients and possibly to arrange transportation for them.

Key Questions to Ask Your Speakers

• What is the difference between hospital costs and hospital charges?
• What are the factors affecting an indigent patient's access to outpatient care?
• What is an "appropriate use" for the ED?
• What are the advantages and disadvantages for the patient of receiving non-urgent care in the ED?
• What are the advantages and disadvantages of providing non-urgent care in the ED?
• What steps have been taken to reduce hospital overcrowding? Which ones have succeeded? Which ones have failed?
• How realistic is it to establish non-urgent "fast tracks" as a basic service of the ED? Who should staff them? Is this cheaper and/or more efficient than establishing a separate health care clinic?
• What can medical students do to help patients receive quality primary care free of long waits and prejudices?

Give your speakers plenty of time to consider these questions and issues before your activity.

Primary Care in the Urban ER
In 1994, there were over 90 million visits to emergency rooms (ERs) throughout the United States.4 Although they account for less than half of the total number of emergency departments, urban EDs shouldered nearly 80% of this volume. A disproportionately large percentage of these visits were made by Medicaid and uninsured patients seeking non-urgent care.1,3 However, despite consistently increasing utilization of the ED for non-urgent care, Medicaid reimbursements have been significantly reduced. Furthermore, hospital overcrowding has reached desperate proportions, especially in the inner cities, where both urgent and non-urgent patients alike are leaving emergency departments without seeing a physician or being referred elsewhere. Many argue that reducing the number of non-urgent care visits to the ED will shrink waiting times and budgetary deficits, while others claim that doing so will deny these patients their only link to the health care network. In a political environment that champions the right to universal health care, it is imperative to alleviate the plagued urban emergency departments without sacrificing convenient and accessible health care for the poor and uninsured.

Common obstacles to medical care 14

• lack of transportation
• lack of telephone
• unable to read a newspaper
• less than high school education
• exposure to violence
• living in supervised setting or shelter
• need for after-hours medical care

We have no place to go!
Evidence shows that having a primary care physician promotes overall improved community health. In New York City, minority populations without a primary care giver were 3.5 times more likely to be hypertensive.20 Also, patients receiving blood pressure checks or blood pressure medication prescriptions in the ED were eight times more likely to be non-compliant with their treatment.21 Unfortunately, despite strong desires to use outpatient care, nearly 50% of the populations that receive non-urgent care in the ED report at least one failed attempt to find care elsewhere. Therefore, it seems to be a myth that indigent patients consciously and deliberately choose the ED as their first option for primary care.

The truth is that the indigent patients seeking medical care in the ED face many financial and nonfinancial barriers to accessing primary care physicians elsewhere. Reports have verified that a patient who does not have a regular physician is more likely to present to the ER with a non-urgent condition than a patient who does.9,19 In a study from Harbor-UCLA Medical Center, where almost 70% of the patients present with non-urgent medical problems, 28% of the sample population reported no regular source of care, and an additional 16% reported using the ED as their regular source of care.13 Interestingly, patients who reported no regular source of care visited the ED just as often as those who identified the ED as their usual provider.

One of the most obvious barriers to care is an inadequate supply and demand relationship. There are not enough primary care doctors in indigent neighborhoods. Of nine low-income minority communities in New York City, only 28 primary care physicians had hospital privileges and were fully accessible to 1.7 million residents.6 It is even harder to find doctors that readily accept Medicaid. A telephone survey of 953 primary care sites in 10 cities revealed that "not accepting Medicaid" was the most commonly stated reason for not granting an appointment, particularly in private doctors' offices (63%). Not surprisingly, repeat calls to 330 private physician offices discovered that 61% of these offices agreed to see a private insurance patient within 2 days. Also, indigent patients often find it difficult to conform to standard office hours, because it requires intolerable wage losses from missed work days. Only 13% of 953 of primary care sites were able to offer after-hours care within two days. This number dropped to 8%, when an additional waiver of a copayment was requested.18

Government funded clinics have not provided much relief, because there are simply not enough in the right locations. In the above study, these sites were most likely to report full clinics that were incapable of taking in any new patients. In the San Francisco area, it can take two months for a new patient appointment in a public clinic.11 Often, these sites are likely to be inaccessible because they are too far away, or don't offer after-hours appointments. Lack of transportation, child care responsibilities and low education levels have all been cited as other barriers to primary health care. 1,13,14

Physicians must also bear some of the responsibility for promoting ED visits for non-urgent care.1,18,29 First, patients denied an outpatient appointment are often referred to the ER.18,29 In 29% of the ED referrals the patients never saw a physician and were presumably instructed over the phone. Second, doctors themselves may not be able to triage urgent versus non-urgent problems. In a study from Harbor-UCLA hospital, 68% of the patients referred to the ED were seen earlier in the day at a physician's office. Ironically, in the two groups, nearly equal percentages of the patients were classified as non-urgent, ambulatory care.29 Perhaps, then, physicians may need more motivation (i.e., more money) to see patients in their office or clinic rather than referring them to the ED.

Why Outpatient Appointments Could Not Be Obtained: 18

The Old Argument: It Costs Too Much
Undoubtedly, maintaining an ED is expensive. Compared to the other hospital departments, the ED is plagued by high fixed costs; they require highly trained staff 24 hours per day, and the use and maintenance of expensive, specialized equipment.3 Also, collection rates are consistently and substantially lower for ED charges versus in-patient hospitalizations.

Because of the patient admissions it generated, hospital administrators viewed the establishment of an ED as an important source of potential income.7 Often the high charges incurred through an admission would more than subsidize the losses assumed from maintaining ED services. Furthermore, the large volume of low-cost, non-urgent service could be charged at a high enough rate to offset the high fixed ED costs. In a study from the Methodist Hospital of Indiana (Indianapolis), Saywell et al reported that approximately 80% of the ED visits were treated as outpatients, accounting for 60% of the ED's total charges.7 In the United States, average charges for non-emergency care in the ER ranged from 1-5 times the average charge of a Medicaid visit in the community.1,3

In the past, the large volume of low-cost, non-urgent service could be charged at a high enough rate to offset the high fixed ED costs. Recently, however, increased deficits from nonreimbursed care prevents this balance.

The 1987 National Medical Expenditure Survey estimated that the difference between charges for a non-urgent ER visit and the same care in an outpatient setting equaled nationwide excess charges of $1.3 billion (in 1993 dollars).28

In addition, the ED has been ineffective in its role as the feeder program for the in-house wards. This increase is easily attributable to the disproportionate number of Medicaid and uninsured patients seeking non-urgent medical care in the ER.1-4 Medicaid patients and uninsured patients increased ED visits 35% and 15%, respectively.3 Over 50% of these visits involved medical care that was later classified as non-emergency.1

This disproportionate rise in ED usage by indigent patients has led to an increase in the amount of uncompensated care. For example, Methodist Hospital of Indiana reported that approximately 35% of total ED charges were written off as bad debt, 60% of which represented the unpaid charges of uninsured "self pay" patients. In New York City, Bellevue Hospital's adult, pediatric and psychiatric ERs collectively lose $13.3 million a year.27 Clearly, the incentive to maintain an ED is vanishing.

A recent publication from the General Accounting Office reported that between 1985 and 1990, the number of ED visits nationwide increased 19%, while hospital admissions decreased about 7%.3

Rebuttal: What's the cost?
The truth is that hospital EDs have always been money-losing ventures. Thus, there really isn't any sufficient data to suggest that substantial cost saving could be realized if the large portion of non-emergency visits were redirected to alternate and less costly primary care sites. As Arthur Kellerman, a strong proponent for primary care in the ED, argues, because of fixed costs it is unlikely that ED operating costs will decline even with successful efforts to reduce non-urgent ED visits.15 In a four-state sample, an estimated savings of $39.5 million was predicted if non-urgent ER visits were reduced 40% in the Medicaid population.1 But an article in the New England Journal of Medicine from March 1996, reported that ED care accounts for less than 5% of annual health care expenditures, roughly $25-30 billion in physician and hospital costs.17 In perspective, a savings of $40 million is an almost negligible drop in the bucket.

Interestingly, a study of community hospitals showed that the marginal cost of a non-urgent visit to the ED was only $24.8 The implication is that, yes, cost savings may be realized if non-urgent daytime ED visits were referred to private physicians; however, the cost to a private physician to open his office to see a patient after-hours or on a holiday is likely to be greater than $24. Put simply, for care during unusual hours it may be cheaper to use the ED. As will be discussed later, many non-urgent visits to the ED are made because the regular office hours of outpatient sites are inconvenient. For care during unusual hours it may be cheaper to use the ED.

Reasons patients leave the ED

• too sick to sit in the waiting room any longer
• had to go home to take care of small children
• problems getting transportation home
• thought somewhere else might have a shorter wait
• changed mind about the need to see a doctor
• angry about having to wait so long

It's Just Too Crowded
As private hospitals try to clamp down on uncompensated care, the increased demand is transferred to public facilities often in excess of their ability to provide adequate care.11 Overcrowding has reached dangerous proportions, particularly in public hospitals. Overcrowding results from a shortage of inpatient beds to meet the demand of new admissions from the ED and transfers from nearby private hospitals. Patients waiting for admission sit idle in ED beds, while more patients enter into the ED waiting room seeking care. Patients have reported waiting anywhere from three to 17 hours before seeing a physician. Concomitant with this increased waiting time is the increased number of patients leaving the ED without being seen by a physician.

Also in 1990, the Harbor-UCLA ED reported that 8.2% of its registrants left before seeing a physician. Of these patients, 75% required care either immediately or at least within 48 hours. After triage, patients who did not see a physician averaged 5.7 hour waits before leaving, compared to four hour waits for patients who did see a doctor. In a follow-up survey, the most commonly cited reasons for leaving included: 1) anger over prolonged waiting, and 2) too sick to wait any longer.10 A similar study at San Francisco General Hospital reported that 15% of its registrants left before seeing a physician, but that the majority of this group had less acute problems.11 Together, these studies show that not only does overcrowding provide a threat to anyone who truly needs emergency services, but it also closes the only door through which many of the poor and uninsured gain access to health care.

Long waiting times for non-urgent patients results in a system of "rationing by queuing," in which the scarce resources of the ED are distributed on the basis of how long people are willing to wait to see a physician. In essence, patients will defer themselves based on how urgent they perceive their need for care to be. Although the data from San Francisco General Hospital supports this theory11, other studies clearly demonstrate the high prevalence of patients who require immediate care, but return to the community without obtaining it. Regardless of which scenario is truly more common, a more effective system to reduce ED overcrowding needs to be implemented to insure that both urgent patients receive necessary care in the ER and non-urgent patients are steered to reliable, timely outpatient facilities.

We've Tried to Fix the Problem!
Many proposals, including copayments for ED visits, limitations on ED visits and even outright refusals of care, have been suggested to address the issue of ED overcrowding.1,2,16,22,23,24 In 1993, Kaiser-Permanente of Northern California reported that instituting a copayment for ED visits resulted in 14.6% decline in visits, compared to control groups, without an increase in adverse events such as mortality or avoidable hospitalizations. The study also reports, however, that at baseline, residents of poor neighborhoods made 22% more visits to the ER than residents of other neighborhoods.16 Thus, requiring copayments from patients that cannot afford them may inadvertently prohibit access to urgent as well as non-urgent care.

Consequently, a handful of research groups are studying the benefit of using triage guidelines to identify non-urgent patients, and the consequences of refusing care to them.22,23,24 In 1989, Derlet and colleagues initiated a five-year study at UC-Davis which used strict triage criteria and focused physical exams to determine patients who could be refused care in the ED and referred to a walk-in clinic or outpatient site. In the first six-months, 18% of ED visits met their criteria for referral. Follow-up revealed that only one percent of 4,186 patients returned to an ED within 48 hours and none of the patients seen in clinics were referred back to the ED. Overall, minor ED visits were reduced from 8,795 to 4,339 and patients who left without being seen decreased from 2,820 to 1,265.24 After five years, the final data showed no instances of gross mistriage or significant adverse outcomes. Thirty-nine percent of the study population received care elsewhere on the same day, and 74% received care within three days.22 Most importantly, only 1.3% complained about having their care referred out of the ED. This data is corroborated by Grumbach and colleagues, who demonstrated in a study population at San Francisco General Hospital that patients with less severe complaints are more willing to trade an ED visit for a clinic appointment within three days.26 Clearly, patients desire the reliability of a regular outpatient care setting.

Unfortunately, the above data may exaggerate the simplicity of reducing ED overcrowding. Lowe and colleagues used the triage guidelines established by Derlet's group to retrospectively study a cohort of patients at San Francisco General Hospital. They found that of 106 patients who would have been refused care by their criteria 35 were, in fact, appropriate visits which eventually led to four hospitalizations.23 Also, at this time, most inner cities have neither sufficient ambulatory facilities nor funding to safely refer patients away from the ED. Without a solid outpatient primary care network, refusing care in the ED may be refusing care outright.

And Why Shouldn't We?
Continued use of the ED for primary care is an accurate barometer of the current quality of health care for patients.12,13 Also, EDs provide comprehensive care, in that patients will not have to return for follow-up laboratory tests, radiographic studies or subspecialty consultations. One stop shopping, if you will. Lastly, prescriptions written in public hospital EDs, and then filled at the outpatient pharmacy are much less costly than those written by a primary care provider and filled elsewhere. Currently, urban primary care sites cannot match any of these conveniences that make long waits at the ED appear better than the other options.

Current State of Affairs
Currently, in many large urban EDs, patients with minor emergencies are referred to treatment areas away from critically ill patients, thereby decongesting intensive care areas. In these situations, referral appointments are setup by hospital staff before the patient leaves the premises. Other institutions, designate specific physicians or physician assistants to minor emergency or walk-in areas, thereby expediting the care of less critical patients. This pattern of staffing is probably more cost-effective than hiring the number of staff needed to keep a physician's office or clinic open nights and weekends.15

Of course, promoting the ED as a primary care site has its drawbacks. Since they provide episodic care to patients, it is not easy to establish a strong relationship with long term continuity of care. Also, integration of care into a multidisciplinary approach is hampered by the inability of the ED (i.e. primary care provider) to serve as the general coordinator of care.30

What Can Students Do?
It is imperative that students understand the severity of the problem. The use of the ED for non-urgent care, particularly in American cities, epitomizes many of the socioeconomic prejudices affecting access to health care for indigent populations. With this knowledge, there are basically two paths towards solution: 1) continued use of the ED for primary care, but with more efficient mechanisms in place to regulate urgent and non-urgent visits; or 2) elimination of some of the currently existing barriers to outpatient care. Which path is easier to accomplish? Continue the debate beyond the scope of this project-in-a box to establish guidelines or policies to improve access to primary care in metropolitan areas. There are many avenues that students can pursue to help relieve some of the stress on urban EDs:

1. Many community health clinics and hospital walk-in clinics are overcrowded and understaffed and would greatly value assistance from medical students to help lighten the load. In keeping these clinics running smoothly, many non-urgent patients may be kept away from the emergency room. Call your local health department to find out where these clinics are located and who to contact.
2. Medical students around the nation have established student-run clinics for poor or homeless patients. You can get involved with an already existing clinic, or start a new one affiliated with your school. Call the AMSA office at (703) 620-6600, to find out more information about founding a clinic. Ask to speak with Nancy Busse at ext. 212. An untried approach is to establish this clinic in or near a hospital emergency department so that non-urgent patients are not sent elsewhere to receive care at a later date. Perhaps a mobile clinic will reach those patients who have limited access to transportation.
3. Establish a transportation network to assist patients who are unable to keep appointments because the public clinic is too far away. This will help maintain the continuity of care which is not available from a hospital ED.
4. Frequently emergency room and health clinic physicians do not have the time to adequately explain to patients about their health problems and needs for follow-up. This situation is exacerbated when patients are unable to read the literature that they are given in place of this verbal instruction. As a result patients return to the ED unnecessarily or after a simple non-urgent problem becomes complicated. Medical students can assist this communication, by attending ED and clinic waiting rooms and acting as the liaison between the patient and the physician. Physicians can then treat more patients without sacrificing educating them.
5. Pursue any ideas spurred by this project-in-a-box
6. Lastly, Columbia College of Physicians and Surgeons offers a one month elective in Urban Medicine and Immigrant Health Care to fourth year medical students. Interested students should contact Jodi Heywood, the Program Coordinator at phone (212) 305-5710, fax (212) 305-6416, or email <jh268@columbia.edu>.

Opportunities for Students

• Visit the triage station in an urban ED
• Volunteer in student-run or government-funded clinics
• Volunteer in the non-urgent section of the ED
• Assist physicians in educating patients about health problems
• Create transportation networks to public clinics

References

1. RP. Use of Emergency Rooms by Medicaid Recipients. Washington, DC: US Dept of Health and Human Services, Office of the Inspector General: 1992.
2. Kusserow RP. Controlling Emergency Department Use: State Medicaid Reports. Washington, DC: US Dept of Health and Human Services, Office of the Inspector General: 1992.
3. Nadel V. Emergency Departments: Unevenly Affected by Growth and Change in Patient Use. Washinton, DC: US General Accounting Office, Human Resources Division: 1993. (GAO/HRD publication no. 93-4.)
4. Hospital Statistics: Annual Survey of Hospitals, 1994-5 Edition. Chicago, IL: American Hospital Association.
5. Report of the National Association of Public Hospitals. Medical Benefits, 1991; 8:5.
6. Brelloche C, Carter AB. Building primary health care in NYC's low-income communities. Community Service Society of New York Working Papers, 1990; iv:5.
7. Saywell RM, Nyhuis AW, Cordell WH, Crockett CR, Woods JR, Rodman GH. An Analysis of Reimbursement for Outpatient Medical Care in an Urban Hospital Emergency Department. Am J Emerg Med 1992; 10:8-13.
8. Williams RM. The Cost of Visits to Emergency Departments. N Engl J Med 1996; 334:642-6.
9. Haddy RI, Schmaler ME, Epting RJ. Nonemergency Emergency Room Use in Patients With and Without Primary Care Physicians. J Fam Pract 1987; 24:389-392.
10. Baker DW, Stevens CD, Brook, RH. Patients Who Leave a Public Hospital Emergency Department Without Being Seen by a Physician. JAMA 1991; 266:1085-1090.
11. Bindman AB, Grumbach K, Keane D, Rauch L, Luce JM. Consequences of Queuing for Care at a Public Hospital Emergency Department. JAMA 1991; 266:1091-1096.
12. Kellermann AL. Too Sick to Wait. JAMA 1991; 266:1123-1125.
13. Baker DW, Stevens CD, Brook RH. Regular Source of Ambulatory Care and Medical Care Utilization by Patients Presenting to a Public Hospital Emergency Department. JAMA 1994; 1909-1912.
14. Rask KJ, Williams MV, Parker RM, McNagny SE. Obstacles Predicting Lack of a Regular Provider and Delays in Seeking Care for Patients at an Urban Public Hospital. JAMA 1994; 1931-1933.
15. Kellerman AL. Nonurgent Emergency Department Visits: Meeting an Unmet Need. JAMA 1994; 1953-1954.
16. Selby JV, Fireman BH, Swain BE. Effect of a Copayment on Use of the Emergency Department in a Health Maintenance Organization. N Engl J Med 1996; 334:635-41.
17. Steinbrook R. The Role of the Emergency Department. N Engl J Med 1996; 334: 657-8.
18. Medicaid Access Study Group. Access of Medicaid Recipients to Outpatient Care. N Engl J Med 1994; 330:1426-30.
19. Pane GA, Farner MC, Salness KA. Health Care Access Problems of Medically Indigent Emergency Department Walk-In Patients. Ann Emerg Med 1991; 20:730-733.
20. Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Predisposing Factors for Severe, Uncontrolled Hypertension in an Inner-City Minority Population. N Engl J Med 1992; 327:776-81.
21. Idem. Correlates of Nonadherence to Hypertension Treatment in an Inner-City Minority Population. Am J Public Health 1992; 82:1607-1612.
22. Derlet RW, Kinser D, Ray L, Hamilton B, McKenzie J. Prospective Identification and Triage of Nonemergency Patients Out of an Emergency Department: A 5-Year Study. Ann Emerg Med 1995; 25:215-23.
23. Lowe RA, Bindman AB, Ulrich SK, et al. Refusing Care to Emergency Department Patients: Evaluation of Published Triage Guidelines. Ann Emerg Med 1994; 23:286-293.
24. Derlet RW, Nishio DA. Refusing Care to Patients Who Present to an Emergency Department. Ann Emerg Med 1990; 19: 262-67.
25. Stock LM, Bradley GE, Lewis RJ, Baker DW, Sipsey J, Stevens CD. Patients Who Leave Emergency Departments Without Being Seen by a Physician: Magnitude of the Problem in Los Angeles County. Ann Emerg Med 1994; 23:294-298.
26. Grumbach K, Keane D, Bindman AB. Primary Care and Public Emergency Department Overcrowding. Am J Public Health 1993; 83:372-378.
27. Finklestein KE. Bellevue's Emergency. New York Times Magazine 1996; Feb 11:45.
28. Baker LC, Baker LS. Excess Cost of Emergency Department Visits for Nonurgent Care. Health Aff (Millwood) 1994; 13(5):162-171.
29. Baker DW, Stevens CD, Brook RH. Determinants of Emergency Department Use by Ambulatory Patients at an Urban Public Hospital. Ann Emerg Med 1995; 25:311-316.
30. Society for Ambulatory Care Professionals. Emergency Services Trendlines. American Hospital Association, 1996.
    

For more information, contact:

Susan B. Cahn, Director of Issues and Research

Society for Ambulatory Care Professionals

American Hospital Association

One North Franklin, Chicago, IL 60606

(312) 422-3903

 

U.S. Department of Health and Human Services

(202) 619-0257

They will send the reports published by the General Accounting Office by request.