Despite the fact that emergency medical departments (EMDs) are the most expensive place to treat a patient, the number of visits to EMDs per year is on the rise, and in more than half of cases, the patient should have received assistance from another level of medical care, typically their family doctor. This overburdening of EMDs has in turn led to increased wait times, detracting from truly needed emergency medical care. In its audit, the National Audit Office determined a number of factors contributing to this situation.
The main obstacle to the normalisation of the situation is the uneven level and accessibility of family health care, long waiting lists for specialised medical care, inadequate IT solutions and patients' varying attitudes and awareness, according to a National Audit Office press release.
There are 19 emergency medicine departments (EMDs) in Estonia, which are based by hospitals belonging to the hospital network development plan. EMDs, the audit noted, are meant for emergencies — acute illnesses, traumas or intoxication.
In its audit, the National Audit Office assessed whether patients who went to EMDs needed emergency care, whether patients who went to EMDs received timely and necessary medical attention prior to turning to the EMD, and whether patients were given timely and necessary followup care, if needed, following a visit to the EMD.
According to the results, 300,000 patients, or approximately every fourth resident of Estonia, visited EMDs approximately 462,000 times in 2017, up 13% compared to 2010 figures. The condition of the patient was life-threatening in just 5% of these cases, however.
Based on a survey carried out at eight of 19 EMDs across Estonia, 49% of the remainder of visits to the EMD, excluding traumas and visits by children, were due to problems that could have been addressed by a family doctor. In 2010, such cases accounted for 39% of visits. For example, the share of patients who visited the EMD at North Estonia Medical Centre (PERH) last year with simpler health problems that could have been treated by a family doctor totalled 55%.
In all, the audit found that 57% of patients who visited an EMD in 2017 had conditions that did not require emergency care and should have received assistance from another level of medical care instead.
The overburdening of EMDs has led to a situation in which the seriousness of a patient's condition could not be determined in a timely enough fashion in almost one fifth of all cases, and in one tenth of cases, the patient did not get to see a doctor as soon as required. The condition of some of these patients, meanwhile, was life-threatening or potentially life-threatening, the audit found.
The EMD is also the most expensive place in Estonia's health system for treating patients. For example, the money spent on visits made to the EMDs at PERH and Tartu University Hospital (TÜK) due to simpler health issues was approximately quadruple the average spent on a visit to a family doctor. In 2017, the total cost of EMDs' medical invoices amounted to approximately €153 million. The amount spent on treatment by family doctors in the same year, in contrast, totalled just €114 million.
The audit revealed a handful of primary reasons for the current overburdening of Estonia's emergency medical departments.
Uneven quality, accessibility of family healthcare
According to the audit, 40% of patients who visited EMDs with less serious complaints reported doing so because they couldn't get an appointment with their family doctor at the right time, while 25% reported not wanting to go to their family doctor for various reasons. It was also revealed that too few family doctors in Estonia offer appointments outside of working hours — just 9% — and their distribution throughout the country is uneven as well. For example, in 2017, no appointments were offered outside of working hours in almost half of Estonian counties, but also bigger cities such as Tartu and Pärnu.
Nonetheless, statistics reveal that approximately 60% of patients with simpler complaints visit EMDs between 8:00 and 18:00 EET on business days, ie during the typical business hours of family medicine centres.
The quality assessment of family medicine practices in 2017, meanwhile, indicated that 43% complied with higher levels, while the remaining practices were assessed at lower levels or had not been assessed yet. Although assessments have been carried out since 2009, approximately one third of family health practices have never been assessed, which means there is no information about the quality level of these practices.
The results of an expert analysis conducted by the Estonian Association of Emergency Medicine Specialists also indicated that the quality of family doctors is uneven — in approximately one fifth of cases, the prior activities of family doctors of patients who ended up visiting EMDs with back pain, hypertension or lower respiratory tract infections had been insufficient. For example, the family doctor had neglected to refer the patient to a specialist, ordered necessary tests or prescribed medicine. The analysis found, however, that the activities of family doctors are mostly adequate.
Nonetheless, if a patient cannot get the help they need from their family doctor, they will seek it elsewhere, the audit found, and the easiest and fastest alternative in the current health system in Estonia is a trip to the EMD.
Lack of coverage for specialised care causes long waiting lists
The financing of specialised medical care does not cover people's need for treatment in Estonia, according to the audit. A total of 245,000 cases were not financed in 2018. The Estonian Health Insurance Fund (Haigekassa) believes that these are cases where people need to see a doctor immediately, but Haigekassa does not have the money to pay for this care. Another €52 million is needed to cover medical care needs this year.
Eurostat data indicates how many people find they have not been able to see a doctor at the right time due to long waiting lists — in Estonia, this perceptive indicator was the highest in Europe. Long waiting lists are one reason why people seek care at the EMD.
Family health, specialised care funding system encourages EMD visits
Hospitals are interested in getting as much money as possible under contract, and visits to the EMD are one way of achieving this, according to the audit. If a patient goes to the EMD with a simple health issue that could be treated by a family doctor, the hospital will still be paid on a service basis, ie for a visit to a medical specialist. Thus, hospitals have no financial motivation to reduce the number of visits to the EMD. The greater the amount of health insurance funding spent on visits to the EMD, however, the less there is left for scheduled treatment, which in turn leaders to longer waiting lists.
Family health care, meanwhile, is financed per capita. A family doctor's income is not dependent on whether and how quickly they admit patients with acute health problems, or how often and with which health problems their patients go to the EMD. In other words, family doctors likewise have no financial motivation to prevent visits by their patients to EMDs, because they likewise lose no money and in fact save time if their patient is treated elsewhere.
The representatives of several hospitals pointed out in the audit that there are family doctors in their catchment areas who refer patients to the EMD even if the condition of the patient does not warrant it.
All of the aforementioned demonstrates that all of the parties involved in the healthcare system have no financial motivation to reduce the number of visits by patients with simpler health issues to the EMD.
Inadequate information systems prevent prevent cooperation of family doctors, EMDs
Due to the administration of the current healthcare system, a family doctor is not notified when their patient visits an EMD, and will only find out about it if a patient on their rolls or their next of kin informs them about it. This lack of necessary information means that a family doctor cannot intervene at the right time following a visit to the EMD to prescribe the followup care needed by the patient.
The doctor who sees a patient in an EMD cannot always obtain an overview of tests and procedures carried out on the patient or a treatment plan previously prescribed for the patient either, as information reaches the health information system with a delay.
Patients not systematically informed
According to the audit, patient behaviour when visiting the EMD as well as prior to and after their visit indicates that people don't know where to turn with their health problems and whether they need to seek treatment at all.
For example, some patients who visited the EMD with less serious problems were unaware that a family doctor could have helped them. They also did not know that they can see a family doctor in case of emergency. Excluding traumas and intoxication, 11% of patients with other health problems had not seen a family doctor at all in the year prior to their EMD visit, and 12% did not see their family doctor in the year following.
Thus, even following a visit to the EMD, some patients do not see their family doctor for followup care and do not follow the prescribed treatment plan. The expert analysis conducted by the Estonian Association of Emergency Medicine Specialists indicated that the health behaviour — which includes appointments with family doctors and medical specialists, taking medicine, getting testing done — of patients who suffered from back pain, hypertension and lower respiratory tract infections prior to seeking care at an EMD had been inadequate in 49% of cases. Health behaviour following a visit to the EMD was inadequate in 34% of cases as well.
According to the current administration of healthcare, doctors, nurses and healthcare institutions are tasked with explaining which problems justify a visit to an EMD, which is why recommendations tend to be based on the staff and organisation of work at a specific organisation. According to the audit, information should be provided systematically to ensure that patients receive the same message from all levels of the healthcare system.
Uninsured people seek care at EMD in poorer health, leading to pricier treatment
As access to other medical care is limited for uninsured people, they often seek medical attention at an EMD after their health problems have worsened. This is why treating uninsured patients ends up more costly. According to Haigekassa, the average medical bill for outpatient treatment of an uninsured patient at an EMD in 2017 was approximately 27% higher than that of insured patients (€84 vs €66), and the average medical bill for inpatient treatment for uninsured patients hospitalised via the EMD was approximately 33% bigger than the bills of insured patients (€2,395 vs €1,803).
Auditor General: More money not the solution
"Treating patients in emergency medicine departments is the most expensive way of doing it in the current health system," Auditor General Janar Holm said in commenting on the results of the audit, adding that EMDs have basically become places where the problems of other levels of healthcare are solved, but more expensively.
"The solutions to enabling EMDs to operate primarily as providers of emergency care lie at other levels of healthcare and cannot be solved by solely by giving more money," he continued. "It is necessary to shorten the waiting lists of medical specialists by using e-consultations more extensively as well as implementing a single digital registration system. The quality of family healthcare should be improved by involving mentors who help family health practices at lower levels to catch up. The establishment of new health centres will make it possible to extend their opening hours, if necessary, to the evenings of working days as well as to weekends for a short time."
According to the auditor general, raising patient awareness guiding their behaviour must also be focused on. "One option for this is to start offering telephone consultations to patients with simpler health problems before they go to the EMD in order to give them the most suitable EMD appointment, refer them to their family doctor or give them instructions for solving the health issue at home," he described. "However, the first precondition to the realisation of these solutions is that the Ministry of Social Affairs and Haigekassa take a stronger leading role in the development of the healthcare system."
Editor: Aili Vahtla