Cost and Visit Duration of Same-Day Access at an Academic Ophthalmology Department vs Emergency Department

This quality improvement analysis evaluates the costs and visit durations of same-day access in an ophthalmology department at an academic medical center vs emergency department care.

Key Points

Question

How do costs and visit duration of same-day access at an academic ophthalmology department compare with those of the hospital emergency department?

Findings

This analysis of data from an electronic record system found that a patient with a nonemergency eye concern would save $782 in charges and 5.75 hours in visit duration by choosing same-day outpatient care rather than an emergency department visit.

Meaning

These results suggest that same-day outpatient care for ophthalmic concerns can be cost saving and implemented successfully in a large health care system.

Abstract

Importance

Convenient outpatient access for ophthalmology patients seeking urgent care could offer savings compared with an emergency department (ED) visit.

Objective

To evaluate the costs and visit durations of same-day access (SDA) in an ophthalmology department at an academic medical center vs ED care.

Design, Setting, and Participants

This single-center study was a retrospective quality improvement analysis of an institutional electronic medical record system at the Wilmer Eye Institute clinics and the Johns Hopkins Hospital ED. On June 1, 2015, the Wilmer Eye Institute and Johns Hopkins Hospital initiated an official policy of providing SDA to patients calling for appointments (ie, the same-day project). All ophthalmology clinic locations created same-day appointment slots for at least 1 practitioner. In recognition of seasonal variations in patient visit volumes, the 10 months before implementation (August 1, 2014, to May 31, 2015) were compared with complementary periods in 2015 to 2016 and 2016 to 2017.

Main Outcomes and Measures

The study tabulated encounters, charges, and visit length for outpatients seen on the same day or by previously scheduled appointments. For the ED patients, volume, diagnoses, charges, and length of stay data were collected. The numbers of SDA patients who indicated urgency were tabulated.

Results

The number of SDA patients increased from 22 781 to 26 579 for the first year after SDA implementation. The mean charge was $258 (95% CI, $250-$266; median, $184; interquartile range [IQR], $175-$320), and the mean clinic transit time was 1.55 hours (95% CI, 1.54-1.57 hours; median, 1.28 hours). For patients seeking eye care in the ED, the mean professional fee was $401 (95% CI, $390-$411; median, $360; IQR, $255-$500), the mean (SD) total hospital charge was $1040 ($999) (95% CI, $729-$1079; median, $1002; IQR, $334-$1429), and the mean length of stay was 7.30 hours (95% CI, 7.01-7.57 hours; median, 7.20 hours). The top 4 ophthalmic diagnoses for ED patients were conjunctivitis, cornea abrasion, iritis, and visual loss, which were unchanged after SDA implementation. In calendar year 2017, a total of 4062 SDA patients reported urgency; their estimated savings in charges compared with an ED visit were $580 866 in professional fees and $3 176 484 in hospital charges.

Conclusions and Relevance

Same-day access appears to be less expensive and to require less time in the health care system than a visit to the ED for an ophthalmic diagnosis. Substantial savings in time and money might be achieved if urgent eye care is delivered in the clinic rather than the ED.

Introduction

Unnecessary use of the hospital emergency department (ED) causes substantial burdens on the health care delivery system, including delays in providing care, longer wait times, and increased costs of care.^1,2,3,4,5 Overcrowded EDs also lead to reduced patient satisfaction^{6,7,8,9,10,11} and increased burnout for personnel.^{12,13,14,15,16,17} To address this issue as it relates to ophthalmology, our department initiated an official policy of providing same-day access (SDA) to patients calling for appointments (ie, the same-day project). The same-day project used the departmental call center to ensure that patients were offered an appointment for the same day that the call was received.

For hospitals in Maryland, there are further complexities not seen in other states. Maryland hospitals are termed regulated space. Regulated space is governed by the 2015 Maryland Global Budget Revenue (GBR) system.⁸ The GBR caps the annual charges that a hospital can generate regardless of patient volumes. One implication of the GBR is that hospitals are incentivized to reduce costs.¹⁸

Before mandating department-wide SDA, a pilot project was instituted in April 2013 in the ophthalmology resident continuity of care clinic (the Wilmer General Eye Services clinic). Of note, this same-day project was part of an overarching strategy to improve efficiency and educational opportunities in this clinic.^19,20,21,22 Positive stakeholder feedback confirmed that this pilot project successfully achieved its goals (ie, demonstrating to other department divisions that SDA could be implemented without creating undue burdens on practitioners, technicians, and administrative staff).

We report the results of the department-wide same-day project, including the estimated numbers of patients diverted from the ED, estimated charge reductions from those diversions, and volumes and length of stay (LOS) in the ED for patients with an ophthalmic diagnosis and complementary data for SDA patients accepting an outpatient appointment.

Methods

The same-day project was officially launched on June 1, 2015. All ophthalmology clinic locations created same-day appointment slots for at least 1 practitioner. Patients were seen by ophthalmologists, postgraduate fellows, physician assistants, and optometrists; there was no hiring of personnel to accommodate patients seen as part of this project. In addition, all types of practitioners used the same billing codes. Internal marketing of the project included letters distributed to all departments and announcements shown on screens located throughout the institution. External marketing included the creation of a page on the institutional website²³ and modification of the script for the call center to offer same-day appointments. The call center associates maintained a running tabulation of the number of patients accepting same-day visits. Later in the project (November 14, 2016), the call center associates started tabulating the numbers of patients who indicated that their problem was urgent or might otherwise have a diagnosis for which they would have sought care in the ED if they could not be provided rapid outpatient access. This study was approved as a quality improvement effort by the Johns Hopkins Institutional Review Board. No informed consent was required because no personal health information was obtained.

In July 2013, The Johns Hopkins Hospital adopted a new electronic health record system (Epic, Epic Systems). Not all functions went live at this date; the tracking of patient LOS in the ED went live August 1, 2014. In recognition of seasonal variations in patient visit volumes, we compared these 10 months before implementation (August 1, 2014, to May 31, 2015) with complementary periods in 2015 to 2016 and 2016 to 2017. Further metrics gleaned from the electronic health record for this study include numbers of patients seen in the ED in general and with an ophthalmic diagnosis in particular, mean charges for those emergency patients with an ophthalmic chief concern, numbers of patients scheduled and seen on the same day in Wilmer Eye Institute outpatient templates as well as their transit time through the clinics, and the mean charges for outpatient visits.

Statistical Analysis

The χ² test was used to compare the number of SDA patients seen before and after implementation and the number of patients with eye concerns who visited the ED. A 2-tailed t test was used to compare transit times through the outpatient clinic and LOS for these patients. The weighted mean of ED charges for patients with eye concerns seen in the ED was calculated by first multiplying the numbers of cases with their mean charges for a particular diagnosis and then averaging those products over the total numbers of ophthalmic patients seen. For all statistical analyses, the P values are 2-tailed. P < .05 was considered to be statistically significant.

Results

Table 1 gives the numbers of patients (same-day and total) seen as outpatients and the mean transit times (check-in to check-out) for same-day and non–same-day patients visiting all ophthalmology clinic locations in the 10 months before implementation and the corresponding 10-month periods for the following 2 years. The number of SDA patients increased for both years after implementation. The number of same-day visits increased from 22 781 to 26 579 from before to after implementation, whereas the total number of outpatient visits increased from 177 690 to 193 902. In the following year, the number of same-day visits increased to 28 171 and the total number of outpatient visits increased to 206 659. The percentage of SDA patients increased from 12.8% to 13.8% from before to after implementation (P < .001) and then decreased to 13.6% (P = .07) the following year. The mean (SD) transit time increased from 1.16 (0.28) to 1.55 (0.94) hours (P < .001) for SDA patients and from 1.18 (0.24) to 1.57 (0.62) hours for non-SDA patients (P < .001) from before to after implementation. In the following year, transit time increased again for SDA patients (to 1.78 [1.77] hours) so that it was longer than the 1.49 (0.84) hours spent by non-SDA patients (P < .001) for the following year.

Table 1. Number and Transit Time of Same-Day Outpatient Visits to an Academic Ophthalmology Department.

Dates	No. of Same-Day Visits/Total No. of Outpatient Visits (%)	Mean Transit Time, h
		Same Day		Non–Same Day
		Mean (SD) [95% CI]	Median	Mean (SD) [95% CI]	Median
August 1, 2014, to May 31, 2015 (before implementation)	22 781/177 690 (12.8)	1.16 (0.28) [1.16-1.17]	1.02	1.18 (0.24) [1.17-1.19]	1.07
August 1, 2015, to May 31, 2016	26 579/193 902 (13.8)	1.55 (0.94) [1.54-1.57]	1.28	1.57 (0.62) [1.56-1.58]	1.38
August 1, 2016, to May 31, 2017	28 171/206 659 (13.6)	1.78 (1.77) [1.76-1.80]	1.40	1.49 (0.84) [1.48-1.50]	1.25

Table 2 gives the volumes and mean LOS for all patients and those with an ophthalmic chief concern who visited the ED in the 10 months before implementation of the same-day project and the complementary period during the ensuing 2 years. The number (2050 [3.7%] to 2227 [4.0%]) and LOS (6.0 to 7.3 hours) of patients with an ophthalmic concern increased (P = .005 for both) from before to after implementation. These metrics did not change the following year (number of patients: 2227 [4.0%] to 2203 [3.9%]; P = .86; LOS: 7.3 to 7.4 hours; P = .51).

Table 2. Number and LOS of Patients Visiting the ED Before and After Same-Day Access Implementation.

Dates	Total No. of ED Visits	Patients With Ophthalmic Concerns, No. (% [95% CI])	Mean LOS, h
			All Patients		Patients With an Ophthalmic Concern
			Mean (SD) [95% CI]	Median	Mean (SD)	Median
August 1, 2014, to May 31, 2015 (before implementation)	56 019	2050 (3.7 [3.5-3.8])	9.1 (7.7) [9.0-9.2]	7.3	6.0 (0.6) [5.5-6.4]	6.0
August 1, 2015, to May 31, 2016	56 371	2227 (4.0 [3.8-4.1])	10.1 (9.3) [10.0-10.1]	7.8	7.3 (0.4) [7.0-7.6]	7.2
August 1, 2016, to May 31, 2017	55 861	2203 (3.9 [3.8-4.1])	10.2 (9.7) [10.1-10.3]	7.5	7.4 (0.4) [7.1-7.7]	7.4

Abbreviations: ED, emergency department; LOS, length of stay.

The first full calendar year during which the call center recorded the number of same-day patients who indicated their medical circumstances might have taken them to the ED if not for being provided rapid outpatient access was 2017. During this year, there were 4062 such patients, and their mean professional charge was $258 (95% CI, $250-$266; median, $184; interquartile range [IQR], $175-$320). A total of 2568 patients visited the ED with an ophthalmic diagnosis this same year, and their mean professional charge was greater by $401 (95% CI, $390-$411; median, $360; IQR, $255-$500). The calculated savings of $143 (ie, $401-$258) per patient allowed an estimate in the annual savings for patients seeking urgent care in the outpatient setting of $580 866 ($4062 × $143).

The 25 most common diagnoses for patients visiting the ED with an ophthalmic concern were also tabulated for these 10-month intervals and are presented in Table 3. The chief concerns were culled; because these codes are specific (eg, allergic vs viral conjunctivitis, left vs right eye), the diagnoses were bundled when reasonable. Although the top 4 diagnoses changed in frequency relative to each other, the only diagnosis in this group that increased steadily was vision change or vision loss from 115 of 2050 cases (5.6%) before implementation to cases in 2016 to 2017 (P = .005). The only other diagnosis in the top 25 that increased steadily during the 3 years was cornea ulcer, increasing from 60 of 2050 cases (2.9%) before implementation to 90 of 2203 (4.1%) in 2016 to 2017 (P = .04).

Table 3. The 25 Most Common Ophthalmic Diagnoses for Patients Visiting the Emergency Department.

Diagnosis	No. of Diagnoses
August 1, 2014, to May 31, 2015 (n = 2050)
Conjunctivitis or pink eye	253
Cornea abrasion	212
Uveitis or iritis	143
Vision change or visual loss	115
Cornea or conjunctival foreign body	81
Eye pain or discomfort	69
Headache or migraine	60
Cornea ulcer	60
Hordeolum, stye, or chalazion	59
Vitreous detachment	57
Cellulitis	56
Subconjunctival hemorrhage or chemosis	54
Retina tear or detachment	47
Glaucoma	46
Orbit fracture	43
Dry eyes	39
Vitreous hemorrhage	33
Keratitis	31
Ruptured globe	30
Optic neuropathy or neuritis	27
Hyphema	21
Cataract	19
Eyelid laceration	19
Cornea, conjunctiva, or scleral laceration	12
Retinal vessel occlusion	11
August 1, 2015, to May 31, 2016 (n = 2227)
Conjunctivitis or pink eye	239
Cornea abrasion	200
Uveitis or iritis	155
Vision change or visual loss	123
Eye pain or discomfort	81
Cornea or conjunctival foreign body	81
Cornea ulcer	74
Subconjunctival hemorrhage or chemosis	74
Vitreous detachment	67
Glaucoma	60
Cellulitis	56
Retina tear or detachment	53
Headache or migraine	52
Hordeolum, stye, or chalazion	49
Orbit fracture	46
Optic neuritis or neuropathy	42
Ruptured globe	35
Dry eyes	33
Eyelid laceration	31
Vitreous hemorrhage	30
Keratitis	23
Hyphema	21
Retinal vessel occlusion	20
Cataract	17
Cornea, conjunctiva, or scleral laceration	16
August 1, 2016, to May 31, 2017 (n = 2203)
Cornea abrasion	225
Conjunctivitis or pink eye	203
Vision change or visual loss	166
Uveitis or iritis	148
Cornea ulcer	90
Eye pain or discomfort	89
Vitreous detachment	77
Cornea or conjunctival foreign body	70
Glaucoma	57
Subconjunctival hemorrhage or chemosis	55
Keratitis	51
Headache or migraine	49
Ruptured globe	48
Cellulitis	46
Retina tear or detachment	46
Orbit fracture	45
Optic neuritis or neuropathy	44
Dry eyes	43
Hordeolum, stye, or chalazion	36
Hyphema	28
Eyelid laceration	23
Vitreous hemorrhage	23
Retinal vessel occlusion	20
Cataract	16
Cornea, conjunctiva, or scleral laceration	10

As mentioned previously, Maryland hospital EDs are regulated space, and additional facility fees are charged along with professional fees. Although facility charges were not captured in Epic during the full time frame of this study, we were able to determine from hospital billing records the mean total charges for the top 11 nontrauma ocular conditions of patients presenting to the ED for fiscal year 2017. Table 4 lists these conditions, the associated mean ED charges, and a weighted mean (SD) charge for the list based on frequency of diagnosis in fiscal year 2017 (ie, $1040 [$999]; 95% CI, $729-$1079; median, $1002; IQR, $334-$1429). Therefore, patients could potentially save up to $782 ($1040 [ED visit] − $258 [outpatient visit]) by choosing SDA. After multiplying this savings by the number of same-day patients who indicated urgency (n = 4062), the potential annualized savings was up to $3 176 484.

Table 4. Charges for the 11 Most Common Nontraumatic Ophthalmic Diagnoses for Patients Visiting the Emergency Department During Fiscal Year 2017 .

Diagnosis	No. of Cases	Charges, $
		Mean (SD) [95% CI]	Median (IQR)
Conjunctivitis	713	493 (484) [457-528]	307 (238-621)
Eye pain	597	1195 (1037) [1112-1278]	904 (618-1580)
Vision changes	364	1638 (1286) [1506-1770]	1312 (677-2174)
Vitreous detachment or opacities	218	1032 (825) [922-1141]	757 (645-1289)
Iritis or uveitis	135	1269 (732) [1144-1394]	1154 (656-1798)
Conjunctival hemorrhage or edema	134	916 (942) [755-1077]	678 (395-1067)
Hordeolum or stye	131	665 (534) [572-757]	548 (266-833)
Cornea ulcer	123	1551 (1085) [1357-1744]	1363 (833-1961)
Keratitis	34	1216 (850) [919-1513]	1111 (584-1389)
Dry eye	27	956 (586) [724-1188]	714 (631-1261)
Glaucoma	71	1755 (1341) [1437-2072]	1477 (761-2205)
Weighted mean (fiscal year 2017)	2547	1040 (999) [729-1079]	1002 (334-1429)

Abbreviation: IQR, interquartile range.

Discussion

Efforts to reduce ED overcrowding are particularly germane for patients with ophthalmic diagnoses, recognizing that almost half of ED visits for these patients may be nonemergency visits.²⁴ Strategies to relieve pressure on the ED include attempts to improve access to patient care in the outpatient setting for nonemergency patients,^{2,25,26,27,28,29} steering nonemergency patients away from the ED,^11,30 and fast-tracking ED patients toward discharge^31,32,33,34 or transfer to an inpatient ward.³⁵ A recent comprehensive review¹ of the literature concludes that an approach that integrates multiple strategies might be optimal.

For hospitals in Maryland, the GBR created a strong incentive to reduce patient volumes or at least to shift volumes from more expensive to less expensive venues, such as from the ED setting to the outpatient clinic. Although the same-day project antedated the implementation of the GBR, it is aligned with the exigencies of this payment system.

Reducing the delay between scheduling an appointment and the date of the visit has been reported to improve the no-show rate for an ophthalmology outpatient clinic,³⁶ and SDA has been reported to improve patient satisfaction with the outpatient setting.³⁷ The incorporation of SDA is also a strategy used by open-access scheduling in which only short-term and/or SDA bookings are created. The open-access model in its pure form has been reported to be associated with reduced rates of kept appointments for a diabetic managed care setting.³⁸ However, with modifications, such as maintaining long-term appointment bookings, the open-access model has been reported to be associated with a reduction in missed appointments²⁵ and improvement in clinic throughput.³⁹

With regard to the financial charge reductions for patients, we calculated that the professional fee charges for an outpatient visit for a same-day patient were approximately 37% less than when that care was provided as part of an ED visit for a patient with an ophthalmic diagnosis. In Maryland, where the use of regulated space adds facility fees, the overall charges for an outpatient clinic visit totaled only approximately 23% of that when care is provided in the ED. Others have reported that the mean charges for the 10 most common outpatient conditions treated in the ED in a 2013 study ranged from $1101 to $4247⁴⁰; this range corrects to $1233 to $4757 in 2017 dollars using the Medical Care Consumer Price Index.⁴¹ In addition, a 2016 study⁴² of Cigna Healthcare claims data reported that the national mean charge for any type of ED visit was $2259 (or $2327 in 2017 dollars when corrected with the Medical Care Consumer Price Index). Therefore, it appears that the mean charges for a patient with an ophthalmic diagnosis seen in our ED in fiscal year 2017 is in accordance with nationwide means. Cigna Healthcare also reported that the mean charge of an urgent care visit was $176 in 2016 ($180 in 2017 dollars). Although this number is lower than the mean charges for a visit to outpatient ophthalmology ($258), it is still consistent with the finding that an ED visit may be costlier than an outpatient visit by an order of magnitude. Charges are generally higher than actual payments made by insurers, although patients without insurance would be subject to the full cost of the charges. Therefore, the savings described would be a maximum, and the actual savings would be substantially less.

Patient volumes at all ophthalmology outpatient locations increased steadily after the implementation of the SDA project. However, the percentage of SDA patients increased only for the year after implementation and then stabilized. Furthermore, the transit time of SDA patients increased in a similar pattern. This finding suggests that SDA patients can be accommodated in practitioner templates but can also expect to spend a longer time in the clinic than patients who booked appointments in advance.

The volumes of patients with eye concerns visiting the ED increased in number and proportionally in the year after implementation of SDA. An evaluation of the top 4 ophthalmic chief concerns suggests that this increase was in part associated with an enrichment of the seriousness of ocular pathology reporting to the ED, considering that visual loss was the only diagnosis in the top 4 that increased steadily. However, the data also support the findings of previous studies^24,43,44 that reported that many patients with eye problems visiting the ED did not have true ocular emergencies.

In the year after implementation of the SDA project, the mean LOS for all ED patients in general and ophthalmic patients in particular increased. There may be differences in the mean LOS depending on the time of day, week, or season. Although the goal of the present study was to assess whether the mean LOS for a patient visiting the ED with an ophthalmic concern was longer than the mean transit time of an SDA patient in the outpatient clinic, future studies exploring how the timing of an ED visit might affect LOS could be useful. It has been reported that determinants of LOS in the ED are multifactorial^45,46 and that social factors contribute greatly.⁴⁷ In addition, the Maryland Hospital Association 2017 Joint Chairmen’s Report indicated that there was an increase in LOS for all Maryland EDs and a tripling of diversions for patients with non–life-threatening conditions during the period contemporaneous with this study.⁴⁸ Because The Johns Hopkins Hospital ED is also the only state-designated eye trauma center in Maryland and would not divert patients with ophthalmic concerns, this could result in a disproportionate share of major eye trauma being sent to our facility.

The Johns Hopkins Hospital has increasingly focused on evaluating patient satisfaction using services such as Press Ganey. We believe that there would be value in assessing whether patient satisfaction with scheduling an ophthalmology appointment improved after implementation of the same-day project, but there were no data available before fiscal year 2016. Same-day access is reported to improve patient satisfaction,^37,49 and other reports^50,51 suggest that patients may care more about factors other than rapidity of access, such as venue and being treated by a particular practitioner.

Limitations

A limitation of this financial analysis is that patients were not randomized to the ED vs the ophthalmology outpatient clinic; there could be confounding variables that distinguish the patient population calling for a same-day appointment compared with the population presenting to the ED without calling. However, many of the top 25 ophthalmic chief concerns of patients visiting the ED in this study could have reasonably been treated in the outpatient setting. Another limitation is that the potential savings calculation assumed that all SDA patients who indicated urgency would have actually visited the ED. It is likely that many patients might have instead waited to be seen in the outpatient clinic at a later date or visited an urgent care center rather than the ED.

Conclusions

Same-day access appears to be associated with an increased volume of patients seen in the ambulatory ophthalmology clinics and reduced costs of care for ophthalmic diagnoses compared with ED utilization. Although patients spend much less time in the outpatient clinic than in the ED, the SDA may be associated with an increase in transit time through outpatient clinics. Although this increase may not be clinically relevant, consideration should still be given to this when creating outpatient clinic scheduling templates. Future research in this area should include exploring ways to raise patient and practitioner awareness of same-day availability through social media and assess not only patient but also employee satisfaction with continued implementation. It would also be useful to evaluate systems to reduce clinic transit time for SDA patients, such as using artificial intelligence to identify prescheduled patients who are likely to not show for their appointment⁵² and then double-booking an SDA patient at those times. Also, whether our results are generalizable to ophthalmology services at other hospitals and even to other clinical departments should be investigated.