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Extended practice hours may reduce emergency room visits


Keeping primary care practices open for more hours, particularly on nights and weekends, reduces patient visits to emergency departments for non-life threatening issues, according to a recent study published in PLOS Medicine.

Keeping primary care practices open for more hours, particularly on nights and weekends, reduces patient visits to emergency departments for non-life threatening issues, according to a recent study published in PLOS Medicine.


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Researchers at the University of Manchester, England, determined that practices that extended their hours beyond the British standard of 8:30 a.m. to 6:30 p.m. had a 26.4 percent reduction in patients seeking emergency department visits for minor problems. The difference amounted to 10,933 fewer ER visits in a year. For every three additional primary care slots booked, one visit to the ER was avoided.

“Extending opening hours in primary care may be a useful addition to policies aiming to reduce pressures on hospital services, potentially reducing patient-initiated use of the emergency department for minor problems-but at a significant cost,” concluded William Whittaker and his colleagues, authors of the study.

While this study was conducted in England, its results may provide useful insights for the American healthcare system, where emergency room visits have long been targeted as an area for reducing the overall cost of healthcare. In 2013, a National Institute of Health study pegged the median cost of a visit at $1,233. If patients had the option of seeing their own physician or a medical professional in their physician’s office instead of visiting the emergency department, this would bring down the overall cost of the patient’s healthcare.

However, the question remains-are longer hours practical for most primary care practices? Nitin Damle, MD, MS, FACP, president of the American College of Physicians and a practicing internist, says they are indeed worth it.


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“We have had after-hours and Saturday morning hours for 15 years,” he says. “We find it helpful to patients, and it seems to decrease ER use modestly along with providing continuity of care.”

Turning to the familiar primary care practice instead of the emergency department provides patients with the benefit of professionals who already know their medical history.

Next: Extended hours require the practice to make commitments of time and funds


“This healthcare team can more easily detect patterns in your health and recommend lifestyle changes to prevent future complications requiring expensive specialty care,” notes Paul Mendis, MD, chief medical officer of the Neighborhood Health Plan in Massachusetts, in the newsletter of the Massachusetts Office of Administration and Finance.


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While patients may be concerned that they will need to wait weeks to see their primary care physician, practices with extended hours are likely to have nurse practitioners and physician assistants on staff to see patients who need attention that day.

“More access in the primary care office, through longer hours, more open slots during normal hours, [and] clinical care teams do provide more continuity of care and prevents some ER visits,” he says.

Yul Ejnes, MD, MACP, an internist in Cranston, Rhode Island, says he finds that patients are more likely to come to his practice rather than visit the emergency department for problems that arise outside of normal business hours. Nevertheless, extended hours require the practice to make commitments of time and funds.

“Opening the office for more hours requires increased staffing and physician time,” he said. “Because of the size of my group, we have enough providers and staff who are interested in extra hours and income to staff the additional hours. This might be difficult to achieve in a small practice.”


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If a practice participates in shared savings with Medicare and other insurance companies, however, “the savings from decreased emergency department use can more than cover the cost of the expanded access,” Ejnes says. “For a small practice whose revenues are from fee-for-service, it may not be as feasible.”

Next: Achieving a balance


Achieving a balance between the time and staffing commitments and the revenue might require some ingenious scheduling, he suggests.

“There are ways to be more creative in scheduling the regular work week,” he says, “such as having some physicians or advance practice clinicians start earlier or later, or even work weekends and evenings, without significantly increasing the number of hours they work each week. Group practices can coordinate how their members shuffle their schedules so that they work the same number of hours, but in the aggregate keep the office open more hours.”


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Ejnes notes that he has worked one evening for more than 25 years, starting his day a few hours later and using that time to catch up on both work and non-work tasks. “Having a couple of free hours during normal business hours makes up for working the one evening,” he says.

Damle’s practice divides the week so that no one works more than one Saturday every eight to ten weeks. “Another option is to hire part time clinicians to staff extended hours,” he says. “If a full-time clinician stays late, he or she may start later in the day, and we adjust staff appropriately.”

“While we need to be open to scheduling our office hours differently in order to provide better access to patients, we also need to be realistic about how much we can do,” Ejnes says. “We need to do things that prevent burnout, not increase it.”

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