Treating the Cause, Not the Symptoms

An editorial to accompany the article: “Synergism of an Urgent Care Walk-in Clinic With an Emergency Department—a Pre–Post Comparative Study” by Bastian Besser, Jan Hendrik Oltrogge-Abiry et al. in this issue of Deutsches Ärzteblatt International

The extent to which the burden on a university hospital emergency department (ED) is reduced by the opening of an urgent care walk-in clinic (WIC) located in the immediate vicinity and offering care between 4 pm and midnight was investigated by Bastian Besser, Jan Hendrik Oltrogge-Abiry et al. (1).

Fewer outpatients in the hospital emergency department

As reported by the authors in this issue, the number of outpatients for a defined patient collective in the ED fell by 37.3%. Treatment times were found to be on average shorter for self-referring outpatients in the ED (17-min reduction), and treatment times were found to be overall shorter for self-referring patients in the WIC compared to the ED (91 min versus 173 min). At the same time, it became clear that there was no reduction in treatment time for any walk-in patients treated as outpatients in the ED—that is, even for those that were referred. This result is surprising, since the WIC did in fact reduce the burden on the ED.

In this regard, the question naturally arises as to whether this measure reduced treatment times for medically high-priority patients in the ED without changes to the staffing ratio, thereby freeing up resources for this group of patients. Unfortunately, the study is not able to answer this question since patients brought to the ED by the emergency services were excluded.

Urgent versus non-urgent emergencies

The deployment of additional staffing resources in the WIC should, in the overall assessment, benefit in particular urgent medical emergencies and not be focused on the prompt treatment of non-urgent cases. This is not least due to the fact that the increasing concentration of emergency medical care in large centers is associated with a continual rise in the number of patients with life-threatening conditions or injuries in emergency departments. Although the total number of outpatients in the ED and WIC did not increase over the study period, this does not rule out, from a methodological perspective, the possibility that provider-induced demand for non-emergency cases develops in the long term.

What also needs to be borne in mind here is that approximately one fifth of patients in the study presented directly to the WIC and were not referred by the ED. As shown in a previous study, there is a significant number of patients seeking medical attention in emergency departments or emergency centersalthough their medical need is not classified as urgent (2).

Strengthen emergency medical care and primary care

Ensuring emergency medical care is a core task of any health care system. The focus of measures must go beyond the treatment of symptoms in order to take the underlying causes into consideration. According to the report of the European Commission on the state of health, 29% of patients in Germany—which is somewhat higher than the European average—visit an emergency department due to inadequate primary care. Therefore, in addition to other structural changes, the report proposes a strengthening of primary care as an important measure (3). The interpersonal continuity encountered in the primary care setting, that is, the personal relationship between primary care physicians and their patients, often spanning a number of years, has been found in other studies to be an important factor that is associated with lower utilization of out-of-hours medical care, lower rates of emergency department referrals, and even with lower mortality (4, 5, 6).

Improve health literacy

Another factor that puts equal strain on the utilization of emergency medical care as well as primary care is the widespread and sadly increasingly low health literacy of the German population (7). The situation is compounded by the fact that due to the complexity and diverse entities of the health care system in Germany, navigational health literacy, that is, the ability to find one’s way around the health care system, is low (7). Thus, not only are structural measures needed but also a conscious behavioral modification on the part of patients. Therefore, it is also crucial to strengthen the health literacy of the population and ensure good knowledge of the existing health care services on offer.

Outlook

As the authors of the article (1) describe, studies are needed in the country-specific health care context. Therefore, future investigations and interventions should focus on the overall picture of care in Germany. To solve the now permanent problem of overburdened EDs, a multimodal approach is likely needed in order to link emergency care structures, strengthen primary care, and improve the population’s health literacy.

Conflict of interest statement
The authors state that no conflicts of interest exist.

Manuscript submitted on 28 June 2023, revised version accepted on 29 June 2023.

Translated from the original German by Christine Rye.

Corresponding author
Prof. Dr. Andy Maun
Institut für Allgemeinmedizin, Universitätsklinikum Freiburg
Elsässer Straße 2m, 79110 Freiburg, Germany

Cite this as:
Maun A, Busch HJ: Treating the cause, not the symptoms. Dtsch Arztebl Int 2023; 120: 489–90. DOI: 10.3238/arztebl.m2023.0125

References

1. Bessert B, Oltrogge-Abiry JH, Peters PS, Schmalstieg-Bahr K, Bobardt-Hartshorn JS, Pohontsch NJ, Bracht S, Mayer-Runge U, Scherer M: Synergism of an urgent care walk-in clinic with an emergency department—a pre–post comparative study. Dtsch Arztebl Int 2023; 120: 491–8

2. Scherer M, Lühmann D, Kazek A, Hansen H, Schäfer I: Patients attending emergency departments—a cross-sectional study of subjectively perceived treatment urgency and motivation for attending. Dtsch Arztebl Int 2017; 114: 645–52

3. European Commisson: State of health in the EU: companion report2017 https://health.ec.europa.eu/system/files/2017-11/2017_companion_en_0.pdf (last accessed on 3 July 2023).

4. Björkelund C, Maun A, Murante AM, Hoffman K, De Maeseneer J, Farkas-Pall Z: Impact of continuity on quality of primary care: from the perspective of citizens’ preferences and multimorbidity—position paper of the European Forum for Primary Care. Qual Prim Care 2013; 21:193–204.

5. Sandvik H, Hetlevik Ø, Blinkenberg J, Hunskaar S: Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. Br J Gen Pract J R Coll Gen Pract 2022; 72: e84–90.

6. Gray DJP, Sidaway-Lee K, White E, Thorne A, Evans PH: Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018; 8: e021161.

7. Schaeffer D, Berens EM, Vogt D, Gille S, Griese L, Klinger J, Hurrelmann K: Health literacy in Germany—findings of a representative follow-up survey. Dtsch Arztebl Int 2021; 118: 723–9.