The mission of the Emergency Medicine Foundation (EMF) is to invest in innovative clinical and health policy research projects that improve the practice of emergency medicine and patient care. Last year alone, the EMF awarded nearly $1 million in grants to emergency medicine researchers. This ongoing article series will introduce some EMF-funded researchers and the contributions their research is making to the field of emergency medicine.

This month, we meet Laura G. Burke, MD, MPH, FACEP, a health services researcher who received a 2018–2019 EMF/ACEP Value of Emergency Care Grant for $150,000 for her project “Trends in the Cost and Quality of Emergency Care.” Dr. Burke is a physician in the department of emergency medicine at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School in Boston.

EMF: Tell us about your EMF grant project.

LB: I‘m a health services researcher, and it’s been frustrating that a lot of the emergency medicine perspective is missing from the narrative around the value of care. There’s been a lot of focus on how emergency care is expensive, that care is becoming more intense, and that costs are rising. That is true, but it’s because we’re doing more for patients in the emergency department, and that has a lot of benefits for patients and the health care system.

With this grant, I was able to look at three issues. First, how have outcomes for people using the ED changed over time? We know care has become more intense, but are patients having better health outcomes? The answer is yes. We looked at 21 million ED visits among Medicare beneficiaries, and we found that their mortality on the day of the ED visit and out to 30 days is improving over time, so thousands of lives have been saved by improvements in emergency care. This was true across hospitals, but it was particularly great for those patients who are the sickest and the most complex. They seem to see the greatest reductions in mortality, suggesting that the changes in the care that we’re providing are actually leading to better health outcomes. That paper is coming out soon.

After we established that health outcomes seem to be improving, we next turned to cost. There’s been a lot of focus on the cost of an individual ED visit. Often, what policymakers aren’t considering is that an ED visit is more expensive than a doctor’s visit but a lot less expensive than a hospitalization. By doing a bit more work in the ED, we can save patients an $8,000 hospital stay. When you look at total cost of care and not just the ED component, we’re actually saving the health care system money in a lot of circumstances.

We looked at that same pool of Medicare beneficiaries and the fact that their admission rate is going down. We’re actually sending more patients home from the ED over time. When you look at just the ED visit, yes, their costs are going up. But when you look at total spending at 30 and 90 days, it’s actually going down. And that’s because we’re using less of the expensive hospital-based care and more outpatient care, which is both more desirable for most patients and less costly. The overall value of emergency care is improving. By doing more in the ED and spending a little bit more up front, we can actually reduce overall spending to the health care system.

The final piece we looked at is how best to measure quality and outcomes. Mortality is a very important outcome, but it’s not the only one. We developed a measure called “healthy days at home” with the Medicare Payment Advisory Commission. It looks at the total time a patient spends alive and out of health care or facility-based health care settings. We found that, over time, EDs are allowing patients to spend more time with their families. They have more healthy days at home because they’re dying less often and they’re spending less time in facility-based health care. This was particularly exciting for me because early literature had suggested this might be true.

It was great to have the time and the space to pursue these research ideas and really use data to show how emergency medicine is improving overall outcomes and costs for patients using the ED.

EMF: Why did you choose this research topic?

LB: This research topic builds upon work I had done previously. I love topics that take a commonly held view in health services research and look at it to see if it’s actually a myth.

My colleagues and I had done some work previously showing that emergency care had become more intense and that admission rates were declining, but we weren’t able to say yet if this was leading to better patient outcomes or lower costs. Building on work that suggested that the narrative around emergency medicine was a bit shortsighted and misguided led us to consider these questions.

EMF: What do you view as the most significant impact of your EMF research grant?

LB: We’re hoping to change the narrative around emergency care. Emergency physicians understand that we’re doing more work in the ED but that it has real benefits for patients. A lot of cost discussions miss the bigger picture. The fact that the ED can actually save money for the broader health care system is an idea that has filtered out to other specialties but hasn’t been generally understood or accepted. I’d like that to be part of the broader health policy narrative. I want to change the conversation to make sure that policies that impact emergency medicine really recognize the value that emergency medicine provides and understand the entire picture of the acute care delivery landscape.

EMF: How did your EMF grant help advance your career in emergency medicine?

LB: This grant has been instrumental in giving me the time and funding to work on projects I think are of major policy importance. We have a paper accepted at a major peer-reviewed journal coming out soon. I’m very excited about that, and I’m hoping to get the rest of our research out there to show that the work that emergency physicians are doing is having an impact. The grant helped me have the time to learn about this topic area, improve my research skills, and meet other health services researchers both inside emergency medicine and beyond.

The EMF grantee workshop helped me meet high-quality and impactful mentors who have given me ideas for moving forward. It has created a community of fellow emergency medicine researchers that I know will be useful in advancing my career in the short- and the long-term as well. I have a number of additional grants and projects in progress that have built upon the work that I’ve done with my EMF grants.

EMF: Do you have a message for the donors and supporters at EMF?

LB: Thank you so much for your support of this organization. It is really critical because a lot of these ideas and topics don’t fit with traditional funding mechanisms. Having a source of funding to delve into the topics that really impact emergency medicine is crucial for the advancement of our specialty.

I’m incredibly appreciative of EMF’s support, and I would encourage other researchers to apply for this grant. I’m grateful to have the support and to be able to work with this terrific community of physicians and scientists.