Why do patients bypass the nearest hospital

It is expected that the EMS provider will consult with a medical control physician, should there be questions of protocol, policies, procedures and transport destinations.

However, the ambulance crew must be aware of the emergency care capabilities of such facilities at the time of the patient request. Patient transfer can be arranged following emergency care and stabilization. In such cases, the EMT should fully document the patient's request and the reasons for the alternate destination decision, including any medical control consultation. A hospital may notify the EMS system of a temporary inability to provide care in the emergency department ED and request ambulances divert patients to an alternate hospital facility.

A request to divert to another facility may be honored by EMS providers. A diversion request does not mean the hospital ED is closed, but usually means the current emergency patient load exceeds the Emergency Department's ability to treat additional patients promptly. If the patient's condition is unstable and the hospital requesting diversion is the closest appropriate hospital, ambulance service personnel should notify the hospital of the patient's condition and to expect the patient's arrival.

This procedure should also be followed when a patient demands transport to a facility on diversion. Stephen Weber, chief medical officer. The hospital became a Level I trauma center in and opened an expanded emergency department at the end of , in part to try to mitigate overcrowding in the emergency room, he said.

The hospital spends less time on bypass now than it did in , Weber said, but its numbers are still relatively high. The trauma center went on bypass when 2, U. Medical Center nurses went on strike last week. At Advocate Christ, a renovation of the ER that included the addition of 26 adult beds could help address increased demand for services, said Nancy Burke, director of emergency services at the hospital.

The hospital has been on bypass less often in recent years, according to the letter. She said that when emergency department is on bypass it still accepts ambulances transporting critical patients, such as those having heart attacks or strokes, as well as trauma patients whose condition is severe. If a hospital is on bypass but the next nearest one is more than five minutes away and a patient needs to be seen immediately, paramedics can work with hospitals to override the bypass, Langford said.

That rarely happens, he said. Not everyone thinks bypass is harmless. More than 10 years ago, in , the Institute of Medicine said the practice should be eliminated except in extreme circumstances, such as mass-casualty events. The institute is now called the National Academy of Medicine and is a private, nonprofit organization. A study, published in the peer-reviewed journal Health Affairs, found that long periods of hospital bypass were associated with a higher likelihood of death among Medicare patients in California experiencing heart attacks.

In January, the Milwaukee Journal Sentinel reported on the case of a year-old Milwaukee woman named Tiffany Tate who in suffered a stroke just yards from a hospital with a top-level stroke center.

Because that hospital was on bypass, she was taken to a different hospital. She later died. Milwaukee County eliminated ambulance diversions altogether in April and had already started working on a plan to do so when Tate suffered her stroke, the Journal Sentinel reported.

Many feared the Massachusetts ban, which began in , would lead to more crowded ERs and ambulance delays. In fact, at nine Boston-area hospitals, on average, patients spent slightly less time in the ER and ambulances turned around slightly faster.

Laura Burke, lead author of the study and an assistant professor of emergency medicine at Harvard Medical School. Fourth, did the self-reported experience of individuals who bypassed differ from those who did not bypass? All study participants provided written informed consent. Extended description of the data collection methods used by PMA can be found elsewhere.

The survey was powered to estimate the modern contraceptive prevalence in women of reproductive age ie, years. Data were collected in partnership with the Kwame Nkrumah University of Science and Technology and included a specially designed primary health care module integrated in the existing PMA facility and household surveys used to track progress toward family planning use targets. Surveys were administered in English and local languages.

To obtain the data, the Ghana Statistical Service selected enumeration areas across all 10 regions with probability proportional to size using a master sampling frame stratified by urban-rural areas. Within these enumeration areas, 42 households were selected using a random start method to complete the household survey, and all members of the household were surveyed.

All data used in this study were collected during round 6 of the PMA survey conducted in late The woman was then categorized as having bypassed her nearest facility or not. We examined 5 categories of variables and their association with bypassing: demographic characteristics ie, age, marital status, educational attainment, household wealth, residence [urban or rural] , utilization of care ie, facility type visited, reasons for seeking care, for whom the care was sought, factors considered most important in the choice of health facility , financial costs, responsiveness of care, 36 and self-reported patient experience.

The responsiveness index was divided into quintiles and dichotomized into highest quintile vs all others. A detailed list of variables and descriptions for each category can be found in the eAppendix in the Supplement. All women who responded to the survey and had visited a health facility in the last 6 months were included in the analyses.

To generate nationally representative, population-based estimates, we used survey-weighted summary statistics that accounted for the multistage clustered survey design in all analyses.

Outcomes were dichotomized as highest or most positive ratings vs all other ratings combined a top-box categorization. The exponentiated regression coefficients from the Poisson regression can be interpreted as relative risks RRs comparing the proportion of those giving the highest rating between women who bypassed and those who did not. We used linear regression with robust SEs to estimate mean out-of-pocket costs paid by women who bypassed and those who did not.

All models were first fit unadjusted for other variables, and then with adjustment for demographic and geographic factors and reasons for seeking care eAppendix in the Supplement. P values were 2-sided and reserved for model-based analyses and not descriptive statistics to avoid issues of multiple testing. We performed analyses in Stata version A total of women met eligibility criteria, and women All women were asked whether they had visited a health care facility within 6 months prior to the survey.

Of those who answered the health care facility question, women All women answered the bypass question. Of women who had sought health care in the past 6 months, 28 1. Therefore, the sample of interest for this study included women who had sought care in the last 6 months and lived in the sample household, which was women after reweighting to account for the survey design eFigure in the Supplement.

Table 1 provides summary statistics for the sample, stratified by bypass status. Using methods accounting for the multistage sampling design and rounded to the nearest integer, women A total of of rural women Women in urban areas tended to be wealthier than those in rural areas, with women There were few women in the highest quintile of wealth in rural areas; however, these women had higher levels of bypassing than the wealthiest women in urban areas eTable 1 in the Supplement.

Women who bypassed their nearest facility were more likely to be seeking care for themselves as opposed to for a child or other family member or friend than women who did not bypass women [ Women who went to their nearest facility more frequently reported going for vaccinations than women who bypassed women [ In particular, the proportions of women who sought care owing to a community health worker referral were similar among women who did not bypass and those who did 13 women [1.

Some women may have self-referred to a more distant facility for strategic reasons. To further examine these patterns, we performed a sensitivity analysis in which we examined strategic bypass.

This analysis included only women who bypassed their nearest facility because it was closed or did not offer their desired services. After looking only at this selected group of women, we found no significant differences in our primary findings eTable 2 in the Supplement. Rural women who bypassed typically did not seek care at community-based health planning and services facilities eTable 1 in the Supplement. Instead, women who bypassed frequently sought care at hospitals or polyclinics and private facilities.

Wealthy rural women were also much more likely to bypass their nearest facility than their urban counterparts eTable 1 in the Supplement. Regardless of bypass status, the 3 highest-ranking factors in choice of health care were competency of the clinician with clinician defined as anyone who provides clinical care women [ Among women who bypassed, women Women who bypassed reported a variety of reasons why they bypassed their closest facility, of which the most commonly reported reason was that their closest facility did not provide the services that they needed of respondents [ Women who bypassed generally reported receiving more responsive care Table 4.

In adjusted Poisson regression models, women who bypassed were more likely to rate the following characteristics as excellent compared with nonexcellent ratings: clinician choice RR, 1. After covariate adjustment, women who bypassed were less likely to report excellent physical health RR, 0.

The full list of adjustment variables is presented in Table 4. Women who bypassed were more likely to have borrowed money to pay for their care RR, 1.

Using linear regression and adjusting for reasons for seeking care and other factors, women who bypassed reported paying a mean of Even after adjustment for other factors, including reason for seeking care, women who bypassed paid nearly 2-fold as much for their care as those who did not. This survey study used a nationally representative survey to estimate the countrywide prevalence of health facility bypass in Ghana.

We found that bypassing was relatively common: Moreover, bypassing was mostly owing to the knowledge that the desired services were not available at the closest facility. Women who bypassed cited clinician competence as the most important factor in choosing a facility more frequently than women who did not bypass, indicating that women highly value competent clinicians and are willing to travel farther to get them.

In rural areas, wealthier women tended to bypass more frequently, suggesting differences in behavior and functional access between socioeconomic strata. Women who bypassed paid more out of pocket for their care than women who did not bypass. To our knowledge, this is the first study to examine costs associated with bypass in this context.

Other studies have examined discrete choice experiments of health facility utilization and quality and found that patients are generally willing to pay more for higher-quality services, although how much more is greatly dependent on context. However, comparisons of bypass across countries can vary widely depending on the service being sought and the distribution of facilities offering that service.

The nearest facility was a mean of 1. In contrast, a study of utilization of childbirth facilities in Ghana 38 found that women lived a median 3.

These differences reflect heterogeneities in opportunity for choice of facility, proximity of facilities offering a desired service, and burden associated with bypassing the nearest facility. Our population of women was also fairly young and as such, less likely to be seeking care for the types of chronic conditions and serious illnesses that might be associated with referral to hospitals. Women generally reported similar reasons for seeking care whether they bypassed their nearest facility or not.

There are limited published data from other low- and middle-income countries on differences between individuals who bypass and those who do not in reasons why individuals might seek care. A study by Gauthier et al 11 examined reasons for seeking care by facility type in Chad and reported that malaria and diarrhea were the primary reasons for seeking care; however, the study did not assess whether these reasons differed by bypass status.

Previous studies 4 , 6 , 9 - 11 , 18 , 19 , 39 have suggested that bypass is frequently driven by perceptions of the quality of care offered. In our study, women who bypassed were more likely to rate their clinician choice, cleanliness of the facility, and privacy as excellent. However, despite rating these aspects of their facility highly, women who bypassed were no more likely to report excellent ratings for the overall quality of their care or to recommend the facility highly to others.

This finding may be associated with differential expectations of what is considered to be acceptable care, with individuals who bypass having higher expectations than whose who do not. Taken in the context of a growing emphasis on quality in health care delivery, our results have important policy and public health implications.