Primary care and emergency department decision making

To determine the effect of primary care status on decision making in the pediatric emergency department (ED).

Urban tertiary care children's hospital.

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.

We prospectively surveyed care for patients with triage temperature of 38.5 degrees C or higher or symptoms of gastroenteritis between August 1, 1999, and February 15, 2000.

Intravenous fluid use, hospital admission status, rates of diagnostic testing and interventions, mean total costs, and length of ED stay.

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.

In this patient population, ED physicians may vary their assessment and management decisions based on primary care status.