The Capital BC CHIP process improvement study, based on the questions posed to PaACEP, rests on several assumptions: 1) that some undefined percentage of current CHIP beneficiary ED visits would be better served if seen in some other venue; and 2) that some subset of these ED visits may be categorized as “unnecessary.”

With respect to the “other venue” assumption, there is a further assumption that such other venues in fact exist for CHIP beneficiaries in a meaningful and consistently accessible fashion. This argument from Access, while dependent on the structure and dimensions of the Capital BC network and therefore beyond the province of PaACEP to either know or judge, is nonetheless a critical determinant in the treatment venue selected by CHIP beneficiaries. Clearly, PaACEP is in no position to determine Captial BC CHIP program structure and resource allocation; however, to the extent that current structures and resource allocation may be subject to analysis and process improvement, PaACEP will endeavor to outline barriers to care and potential solutions based on the medical literature.
As to the existence of “unnecessary” ED visits and their scope, the embedded assumption is that the medical necessity of the encounter can be determined prospectively, i.e., prior to the actual clinical assessment of the patient. Retrospectively, there are certainly ED encounters in which no serious medical problem is found, but the linkage of this fact to the concept that such encounters should have been handled differently is at best vexatious if not impossible, since it was only the real-time clinical encounter that allowed this determination to be made. The difference between a pediatric rash due to bug bites from that of the cutaneous manifestations of meningococcemia serves to illustrate this point.
Attempts to sort ED patients by “emergent” versus “non-emergent” criteria prospectively have proven problematic. While use of the so-called “Billings Algorithm”, developed at New York University retrospectively identified ED patients categorized as “Non Emergent”, “Emergent, Primary Care Treatable”, and “Emergent ED Care Needed, Preventable/Avoidable”, the authors were careful to point out that their findings of relatively high incidences of these patient categories “…do not necessarily mean that ED utilization patterns…are inappropriate.” They go on to note that, “much of what may seem like misuse of emergency services may actually be a reasonable response to an underdeveloped primary care delivery system that is failing to meet patients’ needs.” More recently a study at NYU, where the Billings Algorithm was developed, showed that the use of these criteria in function of discharge diagnosis failed to meaningfully sort out emergent from non-emergent ED visits. These authors conclude: “Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits.”