To our knowledge, this study is the first to provide a snapshot of the scope of preventive care offered in US EDs beyond high-volume, urban academic centers. Most (90%) EDs offered preventive services, although there was large variability in which services were offered. It is also the first to define ED director priorities for preventive services, as well as perceived barriers to implementation.
HIV screening was the least prevalent of the 11 selected services, available in only 19% of EDs surveyed, suggesting that the majority of US EDs were not offering routine HIV screening, as recommended by the 2006 CDC guidelines (all patients aged 13 to 64 years). We also found low interest in offering HIV screening among ED directors relative to other preventive health services. Thus, proponents of ED HIV screening, such as the CDC, will need to demonstrate that HIV screening is not just a worthy priority among the competing priorities for acute care but also a priority among the other preventive services that ED directors appear to prefer.
Intimate partner violence screening was the most prevalent of the 11 services, available in two thirds of EDs surveyed. Although high, this prevalence fell surprisingly short of national mandates and targets. Our study suggests that one third of the nation’s EDs may not be compliant with The Joint Commission mandate, which has required policies and procedures for intimate partner violence screening in hospitals and clinics since 1992.
Our survey is also the first to provide baseline estimates of the prevalence of 9 other services. Even if the absolute percentages were estimated with imprecision, the use of similar surveys over time could uncover important secular trends. Given that most of these services are not currently reimbursable, documentation of actual ED practice, rather than analysis of billing data, would also be useful to validate our study’s results.
Three quarters of ED directors are concerned that offering preventive services would lead to unreimbursed costs. Our findings imply that more widespread dissemination of ED preventive services will likely be contingent on improved reimbursement. ED directors were also concerned about the potential for increased patient length of stay and resource shifting away from acute care, both of which can lead to ED crowding, which is associated with worse patient outcomes. Finally, most ED directors cited inadequate access to follow-up as a reason why preventive services may not be effective in the ED. It can be argued that it is imprudent to screen patients for asymptomatic diseases if they do not have follow-up. Thus, it is not surprising that primary care linkage was the most desired service by ED directors.
Only 27% of ED directors thought that preventive services should not be offered in the ED, which implies that 3 of 4 ED directors are not philosophically opposed to offering preventive care in the ED. Thus, if the other concerns can be addressed, then ED directors may be more willing to implement preventive services.
In summary, most US EDs offer preventive services, but the individual availability and ED director preference for type of service vary considerably. Given these new data, champions of individual ED preventive services will have to justify their service not only among competing acute care priorities but also as a priority among the other preventive services that ED directors seem to prefer. Although most ED directors are not opposed to providing preventive care in the ED, increasing reliable linkage to primary care remains a top priority. Future research to determine the comparative effectiveness of ED preventive services should also analyze their effect on costs, patient flow, and safety, which are concerns for the majority of ED directors. This critical knowledge would guide policymakers and ED directors on implementing the most cost-effective services (acute or preventive) for improving the overall health of ED patients.