• Unnecessary visits to the ED aren’t as common as you think

    One of the things I hear all the time is that emergency departments are increasingly being used for primary care. Because care there is more expensive, it makes the health care system cost a lot more. I also hear that it’s Medicaid people most often “abusing” the emergency department (often because people “say” that no doctors will otherwise see them). There was a recent research brief put out by the Center for Studying Health System Change that looked at exactly that:

    Two kinds of information from emergency department visits generally are used to explain ED use—patients’ symptoms when they arrive at the ED and their diagnoses when they leave. The urgency of symptoms can help explain why a patient chose an ED for care rather than another setting, such as a primary care physician office or clinic.

    Triage staff measures urgency when patients arrive at the emergency department by assessing the severity of symptoms and deciding how quickly patients need to be evaluated. The resulting measure of visit acuity was classified for this study into the following five categories:

    (1) emergent—patient needs to be seen immediately or within 15 minutes of arrival;
    (2) urgent—15-60 minutes;
    (3) semi-urgent—1-2 hours;
    (4) nonurgent—2-24 hours; and
    (5) no triage or unknown triage.About 15 percent of both Medicaid and privately insured ED visits in the 2008 NHAMCS lack assignment of triage acuity for a variety of recordkeeping reasons.

    What did they find? Let’s look at triage acuity:

    The most important take home point here is that even for Medicaid, less than 10% of emergency department visits were “nonurgent”. Would it be better if that was zero? Sure. but we want to accept that a certain number of people who don’t need the ED come, because we’d rather that than have a real emergency not come. Here’s another way of looking at it. We expect that we will take out a certain number (greater than zero) of normal appendices each year, because we’d rather operate on a normal appendix than chance an inflamed appendix not getting surgery. This is the way things look when you’d rather err on the side of caution.

    The other thing to note is that there isn’t that much of a difference between Medicaid and private insurance. There is one, yes, but it isn’t that big.

    Most people are using the emergency department for care that is some level of “urgent”. You have got to remember that doctors offices are open for maybe 50 hours a week. That means they aren’t open for the other 118 hours. When a patient needs to be seen within 2 hours or less, there aren’t a lot of other options. People need somewhere to go. More people have difficulty seeing a doctor on nights, weekends, and holidays in the US than in most other countries:

    A lot of life takes place during nights, weekends, or holidays. You have to expect people to use the emergency department. The vast majority seem to be using it appropriately.

    @aaronecarroll

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    • I do remember reading a study several years ago regarding us of the ED and Medicaid members accessing it because the lack of specialists that take Medicaid patients. This is a very interesting look at things, but for me I am always looking for more. Mainly has this always been the trend or something that is relatively new.

      A couple things that we are graded on by payers is keeping people out of the ED. For our PCMH certification we are graded on access to urgent care and how we educated our patients about using urgent care facilities. Another thing is ED utilization using a NYU algorithm that accesses for Primary Care Sensitive (PCS) conditions, which could be treated outside the ED with a goal of lowering that rate.

    • One other thing to consider is that ‘nonurgent’ medical conditions eventually become ‘urgent’ if they’re left untreated for long enough. A common scenario in my ER is a patient who’s had a cavity for three months, has been unable/unwilling to schedule an appointment with a dentist, and eventually presents to the ER with a fever, leukocytosis and dental abscess requiring drainage. This would be classified as ‘semiurgent’ in the study you cite but in my eyes is truly a ‘nonurgent’ condition.