HealthDataBuzz Investigative Analysis

A recent study that examined the cost of hospital-based and freestanding emergency departments compared to urgent care centers in Texas had some intriguing findings: The prices for patients who were treated at emergency departments instead of urgent care centers paid as much as 10 times higher for similar diagnoses.

This morning, The Washington Post ran a front-page story that said: “Free-standing emergency departments offer convenience, but they may drive up costs.” The article quoted one of the study authors.

Yet the study’s findings are controversial and so is the behind-the-scenes maneuvering involving the study itself, Health Data Buzz has learned.  At the center is the publisher of the manuscript, the Annals of Emergency Medicine, which pulled the study for further review following “serious concerns” over data in the article, even after it was the focus of stories in Texas publications.

The dispute apparently began after emergency department physicians complained about the study although those in the urgent care community certainly have applauded the article fact-finding and conclusions.  The  Annals of Emergency Medicine (AEM) is the official journal of the American College of Emergency Physicians, the Texas-based organization whose more than 31,000 members run emergency departments, not urgent care centers.

The unfolding review process has been so intense the editor-in-chief said he has never had such an experience before involving a manuscript, while the top author says she has never felt so mistreated in the handling of the study.

Recently, the AEM halted publication of the study, Dr. Michael L. Callaham, editor-in-chief of the Annals of Emergency Medicine, confirmed in an email exchange. Callaham is founding chair and professor emeritus of emergency medicine at the University of California-San Francisco Medical Center at Parnassus.

Callaham said the journal’s concerns were about accuracy and interpretation of the study, which led to complaints from emergency department physicians. Those complaints come after the study was made available to the press.  “I had never had a similarly difficult and prolonged assessment experience with a research paper in my decades of editing,” he said.  That editorial review is still ongoing, Callaham added.

While the journal has begun an inquiry into the study, questions also have been raised by the principal co-author, Vivian Ho, PhD, director of the Center for Health and Biosciences at Rice University’s Baker Institute for Public Policy, about the AEM actions.

During a journal editors’ review of the study, an issue involving data transcription errors was uncovered, but that has been used by AEM officials to wrongly cast doubt on the entire document, she said. “In my entire 20-plus years as a professor, I have never been mistreated like this,” Ho said.

Emergency department physicians have indeed complained about the study, Ho said. But she suggested that they objected to the study’s findings because they were favorable to urgent care centers. While some minor tabulation errors were made, Ho said the study findings should stand, once corrected.

Researchers from multiple state institutions, including Rice University, Baylor College of Medicine, University of Texas Health Science at Houston, the Michael E. DeBakey VA Medical Center and the Blue Cross Blue Shield of Texas, were involved in authorship of the study.

The study researchers examined over 16 million claims submitted between 2012 and 2015 by Blue Cross Blue Shield of Texas. They reviewed how often patients visited freestanding and hospital-based emergency departments and urgent care centers in Texas metropolitan areas.

The dispute underlies the economics of urgent care centers and emergency departments, whether freestanding or hospital-based. Patients routinely go to urgent care centers for relatively mild injuries and illnesses, but sometimes go to emergency departments for similar concerns, although they are more costly and are designed to handle more serious patient needs.

At certain points, their business models collide, which was an important element of the Texas study, and just another interesting element in the sometimes chaotic nature of healthcare politics and pricing.

Study Gets Media Attention

Like many studies, advance copies of the Texas study were received by the media, which treated it as big news, which it is.

The Dallas Morning News, ran a major story March 27:
Patients in Texas who felt sticker shock after a visit to an emergency room often could have saved thousands if they had gone to urgent care, a new study says. Whether back problems, bronchitis or abdominal pain, patients paid $1,000 or more for treatments that would have cost them under $200 in a less expensive facility.

The Washington Post’s story today quoted Ho as having “found a big overlap in the types of conditions for which people seek care: Three-quarters of the 20 most common diagnoses at freestanding ERs were the same as at urgent-care centers.”

In the study that was initially made available to the press, researchers said they compared prices for the top 20 diagnoses and procedures. Texans use hospital-based emergency departments (EDs) and urgent care centers much more than freestanding EDS, but freestanding ED utilization increased 236% between 2012 and 2015, the study said. It added: The average price per visit was lower for freestanding EDs versus hospital-based EDS in 2012 ($1,431 versus $1,842) but prices in 2015 were comparable, ($2,199  versus $2,259.) Prices for urgent care centers  “were only $164 and $168 in 2012 and 2015,” according to the study. “Out of pocket liability for consumers for all these facilities increased slightly from 2012 to 2015,” it added.

In addition, the study said “there was a 75% overlap in the 20 most common diagnoses at freestanding EDs versus urgent care centers and 60% overlap for hospital-based EDs and urgent care centers. However, prices for patients with the same diagnosis were on average almost 10 times higher at freestanding and hospital-based EDs relative to urgent care centers.”

The Journal’s Controversial Change of Heart

Weeks after stories appeared in the Texas media, Callaham and editor journals halted further publication of the study online, pending further reviews. Initially, when asked about it, Callaham would say only that the journal’s initial reviews “raised some issues that needed clarification and the authors themselves later found and reported to us a tabular error.”
When asked for elaboration, Callaham said the paper was published electronically following a number of revisions. At that time, “a number of emergency physicians not directly associated with Annals expressed concern about data accuracy and integrity,” he said.

Callaham noted most of the physicians were members of the ACEP. At that point, the paper was removed from public access, Callaham said. He mentioned there were “new concerns” from “credible expert sources and were of a serious nature,” he noted.
Ho disputes the findings, saying concerns raised “about the integrity of the data analyzed in this study are unfounded.” The “article had undergone peer review, was accepted for publication,” she said. Despite the relatively minor transcription error, “the main results of the paper remain unchanged and are still correct,” she said.

Specifically, the problems unfolded after Dr. Paul Kivela, the incoming president of the American College of Emergency Physicians, citing the transcription errors, then argued that the entire manuscript was unreliable and convinced the editor-in-chief to “pull the article from the internet until an independent third-party can examine the data,” Ho said.

“We are still in the midst of disputing Dr. Kivela’s accusations,” Ho said.

Ho said  the ACEP “controls the journal, and they are receiving complaints from emergency physicians, particularly those who could earn a substantial share of their income from the freestanding ER model.”

Callaham said only he and senior editors decided about the status of the study. They relied on guidelines recommended by the World Association of Medical Editors, the International Committee of Medical Journal Editors and the Council of Publication Ethics (COPE). The COPE algorithms were particularly important, he said.

“All the prepublication discussions and revisions were handled entirely within our traditional peer review process by Annals editors only, although we did engage a larger number of reviewers than is routine,” Callaham said.

He added: “All decisions about this manuscript to date have been made entirely by myself and the senior editors of the journal and will continue to be so as we work through the COPE algorithm. As soon as we have the remaining materials we are waiting, we will proceed so that uncertainty for all parties can be ended as soon as possible.”

“As soon as we have the remaining materials we are waiting, we will proceed so that uncertainty for all parties can be ended as soon as possible,” Callaham added.
It is uncertain what the inevitable repercussions of the study will be: whether it will eventually be reworked or changed substantially or withdrawn.

“That is exactly what we need to determine, whether there are remaining issues that could change the conclusions of the paper, and how to correct them if that is the case,” Callaham said. “Obviously we do not want to publish erroneous information no matter what, but we also do not wish to interfere with the dissemination of accurate and useful research.”

Despite the constant flow of newspaper or media headlines of the study’s findings, the journal itself will still be reviewing how the manuscript got to where it is, and that may take awhile.

“Resolving all these issues needs to be done carefully and will take time; when this is done to the journal’s satisfaction or if it becomes apparent it cannot be done, we will issue a final decision and implement it,” Callaham concluded.

“Resolving all these issues needs to be done carefully and will take time; when this is done to the journal’s satisfaction or if it becomes apparent it cannot be done, we will issue a final decision and implement it,” Callaham concluded.

— By Joe Cantlupe