Last month, a colleague of emergency medicine doctor Daniel Waxman sent him some newly reported findings that took him by surprise. Waxman knew from the title of a press release about the recent paper — “Nearly Half of U.S. Medical Care Comes From Emergency Rooms” — that something was wrong.
Immediately I said, that’s not true. It’s just crazy.
Waxman quickly realized the mistake: The data were based only on care provided in hospitals — much of which, not surprisingly, originates from emergency departments (EDs). But the title of the paper, the abstract, and other places in the text do not specify that. What’s more, the press release about the study says the findings relate to “all medical care.” The journal has since changed the paper, including the title, to make that distinction clear, but not provided any editorial notice indicating the text had been updated. Meanwhile, the press release and news stories about the original study continue to report the “surprising” original findings.
The paper “Trends in the Contribution of Emergency Departments to the Provision of Health Care in the USA” was published October 17 in International Journal of Health Services. The title has since been changed to “Trends in the Contribution of Emergency Departments to the Provision of Hospital-Associated Health Care in the USA.”
A ‘substantial methodological error’
On Oct. 23, Waxman, based at the University of California, Los Angeles, wrote a letter to the journal and cc’d the first author, David Marcozzi at the University of Maryland Medical Center, pointing out the “substantial methodological error.” Three days later the editor responded, asking Waxman to submit a letter:
He didn’t say he was going to retract the paper, which I thought was the only legitimate thing to do.
After about a week and a half, Waxman was ready to send his letter, and he decided to check the paper to make sure it hadn’t been retracted. That’s when he noticed the changes.
Waxman forwarded us a copy of the original paper and the revised version; along with the title, the journal changed the abstract and other places in the paper to specify the findings are about EDs and “hospital-associated” care. For instance, the first line of the discussion of the original paper read:
To the best of our knowledge, this is the first study evaluating the contribution of EDs to the provision of health care in the United States.
It now reads:
To the best of our knowledge, this is the first study evaluating the contribution of EDs to the provision of hospital-associated health care in the United States.
We’ve contacted the journal and first author Marcozzi to ask about the changes to the paper; Marcozzi told us the authors had indeed fixed some errors in the paper:
Additionally, we realized very early after the release of the manuscript, that although our methodology was correctly stated and that the conclusions are valid, the manuscript should have better explicitly stated ‘hospital-associated’ when referencing US medical or health care as it relates to percentages. We worked with the journal’s editor to quickly make those changes, which were accepted.
An incorrect press release
Although the original study now qualifies the results as stemming from hospital-based care, on the press release and many news stories, no such distinction is made. Here’s the first line of the press release from the University of Maryland Medical Center:
Nearly half of all US medical care is delivered by emergency departments…
News stories about the paper — such as by Fierce Healthcare and Health Day — also say the findings apply to “all medical care.” (Some outlets, such as the New York Post, got it right.) What’s more, the second author tweeted about the study, not noting that the findings stem just from hospitals:
Half of healthcare contacts happen in the ED. Time to move past the idea that ED diversion is the goal. Teamwork and position play is the goal. acute care + chronic care + inpatient care + home care = healthcare. https://t.co/m7WqZTZnCN pic.twitter.com/olFUVSIZBy
— Brendan Carr (@Dr_BrendanCarr) October 17, 2017
Marcozzi told us:
Although some news outlets correctly reported the findings of the manuscript as hospital associated, in an effort to address any confusion we are inventorying all news outlets that did cover the study and will be providing them a letter clarifying the findings.
Waxman told us, however, that the damage has often already been done:
People can’t unsee the press release that went around, or the articles that were based on the press release.
Waxman added that it’s “hard to know” whether the initially reported misinformation could have some policy implications:
Whether you believe that the emergency department is the focus of the universe, and therefore we should pay more attention to it, or whether it means policy-makers should double down on efforts to get people away from emergency departments. I’m not sure how it will play out, but either way it’s of huge interest.
Marcozzi said, however, that he believes the revised findings are still significant:
Overall, primary care delivers the majority of our nation’s outpatient care and EDs can’t replace it. That said, the numbers speak for themselves as EDs deliver nearly 50% of hospital-associated care, serving as a safety net for specific communities. There is an increasing percentage of ED visits made by vulnerable and under-represented populations such as Blacks, Medicare and Medicaid recipients, and women. There is an opportunity here. The model of care that EDs offer, timely and comprehensive in one visit, is consumer friendly and could be more widely adopted by the healthcare sector…I believe that with substantial and increasing volumes presenting to EDs, robustly including and connecting emergency department care with all other segments of health delivery would result in more patients evaluated in appropriate settings, better transitions between providers, lower costs and improved patient satisfaction and outcomes. This is a missing component of current healthcare delivery reform efforts. There a path forward, one that would improve healthcare delivery and help bend the cost curve.
Update Dec. 11 2017, 14:40 UTC: We’ve heard from a representative of the journal, who told us:
We would have accepted the paper in its corrected form and while the findings in the corrected version are less surprising, they are still of considerable interest.
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