Correspondence (reply): In Reply

We are pleased about the lively discussion and the comments that our article has had in Deutsches Ärzteblatt and subsequently in a number of subject-specific and general publication media—they are proof of a high level of interest and the topicality of the subject matter (1). However, the correspondences also show that there are four aspects that need to be clarified.

The contributions from Möckel and Schmiedhofer, von Stuckrad, Swalve-Bordeaux, and Waldeyer-Sauerland all agree that the first key message of our article cannot be derived from the data. They use the total number of patients registered in the emergency departments during the observation period (N=6483) and point out that ultimately, only about 10% of this group in the survey report a low subjective treatment urgency. This calculation included the 5308 patients who did not comment on their subjective urgency, as they were for the most part not included in the survey. In addition, the commentators reformulate the study question using their own interpretation: it was not the intention of the study to make statements about the total population of patients in emergency departments. Rather, it aimed to describe walk-in patients in emergency departments, who make a rational decision to visit the emergency department but who, at least theoretically, have other choices. This is only the case for patients who are conscious, responsive, and not at an immediate risk of death, and who can dedicate the necessary cognitive attention to their decision. Patients for whom the hospital determined immediate or very urgent need for treatment, those with severe functional impairment in hearing, vision, or speech, and those with a—restrictively defined—high level of symptom burden were excluded not only for ethical and research methodological reasons, but also because the research question did not address this group. Whether the patients who were excluded from our study solely for methodological reasons (for example, short waiting times because of low patient numbers, no possibilities for communication due to lacking language skills, etc.) or who were not willing to participate differ from the study population in terms of their subjective treatment urgency cannot be determined based on the available information.

In the correspondence of Dr. Waldeyer-Sauerland, the question about the validity of the measurement of subjective treatment urgency is raised, especially because patients were offered a numerical rating scale but not defined categories. By definition, only the end positions 0 and 10 use defined categories on the numerical rating scale, but not the intermediate categories, and patients had to choose an integer value. The high popularity of the answer category „5“ is most likely due to the respondent’s convenience on the one hand (you do not have to think about it) and social desirability on the other hand (if you do not know what you want, the middle is least susceptible to criticism). Patients who could not decide or did not want to decide how urgently they needed to be treated were included in the „non-urgent“ patient group, where we felt they belong. Patients did not know, based on their self-report, whether they would be classified as urgent or non-urgent patients. This was deliberately chosen as a methodical approach to patient „blinding“ in order to avoid strategic responses.

We also find it regrettable, as stated in the correspondence by Prof. Möckel and Dr. Schmiedhofer, that only about half of the interviewed patients at the time of the survey had an initial assessment of treatment urgency by the hospital staff, and we were therefore very cautious in our interpretation of any agreement between subjective and professional assessment of urgency.

The proposed interpretation from Prof. Möckel and Dr. Schmiedhofer, that primary care physicians „refer“ patients with trauma / skin injuries and low subjective urgency to emergency departments, cannot be concluded from the published results, as correlations at the aggregate level cannot be used to conclude relationships at the individual level.

Finally, we are pleased that our study provides many suggestions for a potentially meaningful reorganization in emergency department care. But our results certainly do not show the only possible „silver bullet“.