The proceedings from this year’s Academic Emergency Medicine Consensus Conference and the contributed papers in this issue highlight some of the promises and problems of doing public health in the emergency department (ED). Several papers show that meaningful public health interventions are possible in the ED, but others make it clear that they can be difficult to carry out without considerably more resources than most facilities have available. This commentary plans to clarify what are meant by public health interventions in emergency care, make a few suggestions about what emergency medicine can do to make a greater difference in the health of the public, and add to the proposed research agenda.
It strikes us that the consensus conference and the papers in this issue, while addressing important initiatives, are limited in scope. The conference and papers focused on clinical preventive services and surveillance in the ED. No article presents a broad perspective of public health activities and a research agenda stemming from those initiatives. What effect would emergency medicine’s community involvement and approaches to achieving political change have on improving the community’s health? What effect would these have on ED volume and patient acuity?
Disease prevention, a primary focus of public health, classically is divided into three categories. Primary includes activities (vaccination, clean water) that prevent the development of a disease. Such activities are usually population-based and are a major focus of primary care physicians and public health officials. Only one article in this issue talks about primary prevention, and basically it proposes a better clinical evaluation of individual patients to improve the risk/benefit ratio to them. Emergency physicians and emergency medicine organizations have been active in primary prevention particularly as it relates to trauma. Including other disease processes that have acute care implications might be useful, and we would be interested in more research about the effectiveness of these efforts. Secondary prevention tries to avoid disease progression by detecting and treating the disease early. This clearly was the conference’s focus. Tertiary prevention aims at patients with established disease and attempts to cure them or at least slow progression and reduce complications. This always has been the essential function of emergency care. We treat and refer. This is why patients seek emergency care. We suggest that any project adding primary or secondary prevention activities should address the intervention’s effect on acute care and tertiary prevention in the ED. This is a real issue: the requirement to do additional preventive care has decreased the amount of time that primary care physicians in the UK have to examine patients.1 Although this tradeoff may be appropriate in a low-acuity clinic, it could be dangerous in a crowded, high-acuity ED. The effect of adding even “brief” interventions within the context of the present system needs to be evaluated, as they will increase the ED providers’ workload. Multitasking is an essential emergency physician skill, but does lead to errors.2
We think it important to discuss the definition of “screening” as it is used in the articles in this issue. It is common today to call any test or evaluation done for disease detection a screen. We believe, as did Sackett and Holland3 over three decades ago, that the loose use of “screening” leads to controversy and confusion. They draw distinctions between tests used for screening, case-finding, diagnosis, and epidemiologic surveys. The essence of screening is that apparently healthy people volunteer to be tested for a condition where early detection and treatment has a better outcome. Case-finding occurs when a patient is tested for a disorder unrelated to his or her reason for presenting. It represents a comprehensive approach to care. The difference between screening and case-finding is more than semantic. Volunteers for screening can expect a better outcome, while patients can expect only the highest standard of care. An ED-based screening program could be organized to have no influence on the patient care process. Questioning and testing could be independent of diagnosis and treatment, although most likely the screening results would be discussed with the patient in the ED. Case-finding is part of the clinical encounter and will affect the time and content of that encounter.
Diagnostic tests are used to identify the exact cause of the patient’s complaint. Screening tests should have high sensitivity, which inevitably results in a high false-positive rate. This, in turn, requires counseling and follow-up. High specificity, on the other hand, is crucial for tests used for case-finding and for diagnosis. This means that the same test rarely is appropriate for both purposes.
Several articles presented in this issue and projects reported in the proceedings were supported with grants or other temporary funds. These studies showed that EDs can do the interventions, but some of these projects proved impossible to continue after funding ceased. Neither of these points is surprising, but it is important that they are recognized. Uncovering domestic violence is a case in point. Questioning a patient who suffered a blow-out fracture “walking into a door” about domestic violence is part of emergency care—it is part of the diagnostic process and tertiary prevention. But who should EDs evaluate for intimate partner violence? Should they case-find all patients, only those at high risk, or should they screen everyone who volunteers? Should they provide screening to those unlikely to get expeditious care elsewhere, when funding is in place and when screening is easy? Even defining these criteria is difficult. Should a chlamydia test be run on all visitors, all patients, all patients who have urine tests, all urine samples from reproductive aged woman, or all urine samples from women with abdominal pain? This is a set of research questions with practical and ethical implications.
Gostin and Mann4 argued that a public health intervention must be carefully evaluated prior to implementation. The questions that need to be answered include: is the public health purpose clear? Is it well targeted and is it likely to be effective, i.e., is screening appropriate and accurate? Will the intervention be effective and is this the best approach? These questions are particularly relevant to ED prevention projects. Screening is useless and unethical unless the patient gets follow-up. Many emergency physicians face significant problems arranging follow-up for tertiary prevention. Expecting them to do so for patients who are not currently ill probably is not realistic. A relevant research question that is important from a policy standpoint is whether it would be more cost-effective to spend the money on prevention in or outside the ED. The slightly higher marginal cost of ED visits may be counterbalanced by more convenient hours for people who find it difficult to get to clinic during business hours, or it may not be.
The argument that we must practice preventive care because these are our patients is a purely clinical one. It is true for tertiary prevention, but is not germane when evaluating primary or many secondary prevention interventions. Early detection of disease and disease risk factors in the ED will reach only a fraction of the total population. If most of the general population is being adequately screened, and the people who go to EDs are not, then screening in the ED is appropriate; otherwise it will have little effect on the overall health of the public. A related issue is that the Agency for Healthcare Research and Quality (AHRQ) currently recommends 70 preventive services.5 Providing a few of them in the ED would not meet the majority of the prevention needs of even those people who present to the ED. This does not mean we should throw up our hands in defeat. It means that primary and secondary prevention activities in the ED should be the subject of comparative effectiveness research.
Public health often addresses chronic problems that require long-term solutions. Early analysis of a trial is useful because if the intervention fails at that point (or is harmful) it avoids wasting resources on the more difficult long-term evaluation. But an intervention that is positive early may have no real public health effect if the factor being studied is one that poses a lasting risk. Evaluation of problems such as tobacco, alcohol, violence, and high-risk sexual behavior requires long-term follow-up. This is difficult, expensive, and essential. There are methodologic rules for trials and public health research must adhere to them. The initial protocol should include a planned endpoint evaluation that is scheduled at a time that is appropriate for the disease process and intervention being studied. The protocol must overtly state plans for any interim analyses, and the sample size should be adequate. The interim results cannot be used to recommend the intervention. A positive interim result must be clearly labeled as such and the final analysis must take place. Once the final endpoint is reached, all publications based on interim results become irrelevant.
It is unfortunate that all the papers in this issue are from the United States. U.S. health care is the least systematic and most inequitable in the developed world. Most of the proposed changes in our health care system envision improving coverage and increasing preventive care. As Porter6 recently said, “…we need to radically reexamine how to organize the delivery of prevention, wellness, screening, and routine health maintenance services. The problem is not only that the system under invests in these services relative to the value they can create, but also that primary care providers are asked to deliver disparate services with limited staff to excessively broad patient populations. As a result, delivery of such care is fragmented and often ineffective and inefficient.” We have much to learn from other nations’ public health systems.
Most papers in this issue are from academic facilities that treat a high proportion of uninsured, socioeconomically underprivileged patients who have difficulty accessing primary care, and we need to be circumspect about generalizing from this population. Likewise, none of the papers are from the three U.S. government systems: the Veteran’s Administration, Uniformed Services, and Indian Health Service. One of the authors of this commentary (MH) works part time for the Indian Health Service. His patients have easy access to primary care and get health screening on an annual basis. Population-based screening makes little sense in his ED. We would like to see more research about public health interventions in EDs under different social and financial systems.
Case-finding in the ED raises two other potential problems. Being tested or asked a series of health questions can be irritating for patients. Indeed, testing is not necessarily benign, and even appropriate screening can cause significant suffering; patients may have long-term psychological harm from false-positive,7 or even negative,8 tests. If we wish to practice patient-centered care, we should at least find out if patients would prefer not to be asked a battery of questions that are unrelated to their chief complaints. Would they accept these in a voluntary screening setting? Llovera and colleagues9 found that patients did appreciate health education while waiting. Research on ED screening should examine this issue as well.
Some prevention is generally accepted as part of emergency care. EDs check for hypertension and vaccinate for tetanus. In addition, EDs frequently diagnose infections and other problems that affect people other than the presenting patient. Research aimed at improving our generally poor track record in these areas would be welcome. Point-of-service feedback is a promising technique; placing a vaccination form on each suture kit makes it easy to remember to administer the Tdap vaccine.
Another important question is whether a “teachable moment” exists in the ED. We believe that it does, but comparing brief interventions done in the ED with those done in clinic still is worthwhile. Recommending counseling to intoxicated patients in the ED, even though they were screened within the year is prudent, but knowing how much of an effect this has would help convince us to do more. A positive ED screen does seem to motivate change. Does it motivate patients to follow-up? This is an important question.
Emergency departments do see a different spectrum of patients than do primary care clinics. We suspect that the homeless, psychotic, alcoholic, and medically phobic always will end up coming to us. Prevention for these patients requires a robust health care system that is able to case-find as part of comprehensive care and to provide care over the long term. One of the real challenges for preventive care is that it needs to occur over the entire life span. Research on how to best accomplish this for our “special-needs” patients should be a priority.
A crucial issue is that emergency physicians and departments do not do much primary and secondary prevention. They may be uninformed, overworked, unmotivated, and unskilled, or perhaps it is just a problem of knowledge translation and habit. These all are plausible, but it is important to find out exactly why prevention is not part of the emergency “job description.” We suspect that failure to deliver more public health interventions is multifactorial. If this is true then combined approaches such as “pushed” data delivery from electronic medical records for case-finding in ED patients, supplemented by screening and treatment in or near the ED by dedicated “preventionist”10 staff may be necessary to make a meaningful impact. This too is an appropriate research topic. Adequate and stable funding is obviously a prerequisite; although ED case-finding generally is covered under the usual billing procedures, coverage for screening often is not.
We agree that routine emergency care should include patient-focused activities that have public health implications, such as smoking cessation for patients with chronic lung disease; these should be part of teaching and practice. We are intrigued by proposals to expand screening and case-finding in the ED. The papers in this issue highlight several promising ideas. But many essential questions remain unanswered. Clear evidence of relative effectiveness must be established before large-scale adoption of ED-based preventive and public health services. We think there is an opportunity for considerably more high-quality research on prevention and emergency care. Hopefully this consensus conference will stimulate us to expand our vision of what may be possible.