There is what regulators intend to happen when they adopt a rule, and then there is what really happens. And seldom shall the twain meet. Researchers submitting a paper to the National Bureau of Economic Research examine this in the case of attempting to improve ER response times. (NBER Paper) the US isn’t the only country concerned about ER use and what happens to patients who go to the ER. The authors of this paper zeroed in on a change that England enacted, whereby in 2004 ERs were mandated to see 98% of patients within 4 hours and either admit them, discharge them or send them to another hospital; that target was subsequently relaxed to 95%. (Seems like forever to us, but in England people are used to waiting for all kinds of care, sometimes for months.) There were financial penalties for failure to meet the target and managers were fired as well. Apparently the policy has been controversial, as some clinicians think it improved care by ensuring that people got seen in a reasonable time and others think it decreased, as patients were just rushed along. Researching the actual cost and quality outcomes of the policy has not been easy and these authors take a new approach. The attempted to identify the impact on wait times by a “bunching” technique and also estimated effects on spending.
They found that wait times tended to spike or bunch around the 4 hour target, suggesting that ER staff was aware of and trying to meet the target. Overall, there appeared to be a 19 minute, or 8%, decline in average wait time. Other impacts appeared to be more intensive testing, which obviously increased costs, and more hospital admissions, but these new admissions tended to be relatively short and inexpensive, although they did drive up inpatient spending by 5%. All of this is consistent with intuition; there is more testing to try to identify what to do with the patients in the ER faster and there are more admissions just as a way to clear people out of the ER, even if they don’t really need to be admitted. Spending has also been increased because most hospitals added staff just to track the flow and progress of patients through the ER. Might be more efficient, and more consistent with optimal care, to have just increased ER staff so there were more people to deal with the patients faster. It appeared that mortality in the 30 days after the ER visit fell 14%, and a year after the visit was still 3% lower. Be interesting to know how much that improvement was concentrated among those who ended up with an inpatient admission. In any event, the regulatory intervention certainly affected behavior, but not necessarily in a manner that optimized treatment decisions. There may have been some very slight reduction in long-term mortality, but spending rose a fair amount.