Primary care and emergency department decision making

Objective: To determine the effect of primary care status on decision making in the pediatric emergency department (ED). Setting: Urban tertiary care children's hospital. Design: Examining physicians prospectively completed questionnaires describing the presence of and their familiarity with patients' primary care providers (PCPs), as well as several relevant clinical factors. Patients: We prospectively surveyed care for patients with triage temperature of 38.5°C or higher or symptoms of gastroenteritis between August 1, 1999, and February 15, 2000. Outcome Measures: Intravenous fluid use, hospital admission status, rates of diagnostic testing and interventions, mean total costs, and length of ED stay. Results: Among 1166 nonreferred patients, no PCP was identified for 164 patients and PCPs for 1002. The groups did not differ on ethnicity, mean age-adjusted vital signs, triage category, initial appearance, patient care setting (main ED or urgent care clinic), time of day, day of week, certainty of diagnosis, or perceived importance of follow-up. Mean unadjusted direct hospital costs for diagnostic testing were significantly higher for the group without PCPs, $23 vs $16. In regression models controlling for age, ethnicity, insurance status, patient care setting, ED attending physician, temperature, and initial appearance, the absence of a PCP was associated with an increased likelihood of diagnostic testing. Compared with a subset of the cohort with PCPs who were familiar to the treating physicians, the group without PCPs also had a significantly higher rate of intravenous fluid administration. Conclusion: In this patient population, ED physicians may vary their assessment and management decisions based on primary care status.