Leah S. Honigman, MD, MPH, Jennifer L. Wiler, MD, MBA, Sean
Rooks, BA, and Adit A. Ginde, MD, MPH
Introduction: Reducing non-urgent emergency department (ED)
visits has been targeted as a method to produce cost savings. To better
describe these visits, we sought to compare resource utilization of ED visits
characterized as non-urgent at triage to immediate, emergent, or urgent (IEU)
visits.
Methods: We performed a retrospective, cross-sectional analysis of the
2006-2009 National Hospital Ambulatory Medical Care Survey. Urgency of visits
was categorized using the assigned 5-level triage acuity score. We analyzed
resource utilization, including diagnostic testing, treatment, and
hospitalization within each acuity categorization.
Results: From 2006-2009,
10.1% (95% confidence interval [CI], 9.2-11.2) of United States ED visits were
categorized as non-urgent. Most (87.8% [95% CI, 86.3-89.2]) non-urgent visits
had some diagnostic testing or treatment in the ED. Imaging was common in
non-urgent visits (29.8% [95% CI, 27.8-31.8]), although not as frequent as for
IEU visits (52.9% [95% CI, 51.6-54.2]). Similarly, procedures were performed
less frequently for non-urgent (34.1% [95% CI, 31.8-36.4]) compared to IEU
visits (56.3% [95% CI, 53.5-59.0]). Medication administration was similar
between the 2 groups (80.6% [95% CI, 79.5-81.7] vs. 76.3% [95% CI, 74.7-77.8],
respectively). The rate of hospital admission was 4.0% (95% CI, 3.3-4.8) vs.
19.8% (95% CI, 18.4-21.3) for IEU visits, with admission to a critical care
setting for 0.5% of non-urgent visits (95% CI, 0.3-0.6) vs. 3.4% (95% CI,
3.1-3.8) of IEU visits.
Conclusions: For most non-urgent ED visits, some
diagnostic or therapeutic intervention was performed. Relatively low, but
notable proportions of non-urgent ED visits were admitted to the hospital,
sometimes to a critical care setting. These data call into question non-urgent
ED visits being categorized as “unnecessary,” particularly in the setting of
limited access to timely primary care for acute illness or injury. [West J
Emerg Med. 2013;14(6):609–616.]
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INTRODUCTION
In 2009 healthcare spending accounted for 17.9% of the gross domestic product in the United States (U.S.), a number that has nearly doubled in the last 30 years. (1) One of the stated goals of policymakers is to slow this growth and increase the value of healthcare spending. (2,3) Some have advocated for policies that reduce “unnecessary” emergency department (ED) visits as a way to generate significant cost savings for the healthcare system. (4)
METHODS
Study Design and Setting
We performed a retrospective, cross-sectional analysis of
the 2006–2009 National Hospital Ambulatory Medical Care Survey (NHAMCS). This
study received institutional review board approval as an exempt protocol with a
waiver of informed consent. A detailed description of the NHAMCS survey methods
is provided elsewhere.(10) Briefly,
the NHAMCS is a stratified, multi-stage probability sample conducted annually
by the National Center for Health Statistics (NCHS). Data were collected by
trained NCHS personnel using a standardized data abstraction form, which were
similar between the study years. During 2006–2009, a total sample of 1,932 U.S.
non-institutional general and short-stay hospitals was selected for
participation in NHAMCS. Of the 1,566 hospitals that were deemed eligible,
1,408 (90%) participated and a total of 140,415 ED visits were abstracted.
Study Protocol
ED visits were grouped by a 5-level triage acuity score
representing immediate, emergent, urgent, semi-urgent, or non-urgent, based on
the triage nurse’s judgment about the patient’s need for immediacy of
evaluation, stabilization, and/or treatment. A level 1, or immediate visit, was
a severe condition where any delay in medical attention would likely result in
death and included a major trauma or medical problem. A level 2, or emergent
visit, required evaluation within 1–14 minutes and represented a severe illness
or injury requiring immediate care to combat danger to life or limb and where
any delay would likely result in deterioration. A level 3, or urgent visit, was
an illness or injury requiring treatment within 60 minutes. A level 4, or
semi-urgent visit, could be evaluated in between 1–2 hours. A level 5, or
non-urgent visit, represented conditions where a delay of up to 24 hours would
make no appreciable difference to the clinical condition and where subsequent
referral may be made to the appropriate alternative specialty. Triage acuity
was missing for 19,024 (13.5%) visits and were therefore excluded from the
primary analysis. Comparative analysis was undertaken to evaluate the excluded
visits with the remainder of the charts with triage level recorded. We
evaluated all remaining ED visits for clinical characteristics and resource
utilization.
We analyzed the visit data in terms of patient-level
characteristics including age, sex, race / ethnicity, and source of payment. We
also analyzed the data by hospital facility characteristics, including U.S.
region (Northeast, Midwest, South, and West), the hospital metropolitan
statistical area status (urban and nonurban), and hospital ownership
(nonprofit, government [non-federal], and private / for profit). Regional and
metropolitan statistical area categories were included representing
standardized geographical divisions as defined by the U.S. Bureau of the
Census. Additionally, we analyzed visit characteristics including arrival time,
day of arrival (weekend or weekday), mode of arrival, and ED length of stay.
We analyzed resource utilization, including imaging,
diagnostic tests, procedures, or medications ordered. Imaging utilization was
subcategorized as cross-sectional imaging, including computed tomography,
magnetic resonance imaging, and ultrasound. Diagnostic tests included blood and
urine tests, cardiac monitoring, electrocardiography, wound culture, and
influenza test. Procedures included intravenous hydration, casting or
splinting, wound repair, incision and drainage, foreign body removal, nebulizer
therapy, bladder catheterization, pelvic examination, central line placement,
performance of cardiopulmonary resuscitation, or endotracheal intubation.
Medications included those given in the ED, as well as those prescribed at
discharge. Finally, we included visit disposition, including rate of
hospitalization and admission to a critical care unit, operating room, or
catheterization lab.
Statistical Analysis
The primary analysis was descriptive, with 95% confidence
intervals (CIs). We adhered to published checklists regarding recommendations
for NHAMCS data analysis.(11,12)We
analyzed clinical characteristics and resource utilization within each triage
categorization and compared the characteristics of non-urgent visits with those
of higher acuity visits, categorized as immediate, emergent and urgent (IEU),
and semi-urgent visits. We performed the statistical analyses using Stata 12.1
(StatCorp, College Station, TX) and used survey commands to adjust for the
complex survey design and weight the sample to provide estimates for all U.S.
ED visits.
RESULTS
In 2006–2009, 10.1% of the estimated 110 million annual U.S. ED visits included in the primary analysis were categorized as non-urgent. Table 1 shows clinical characteristics of ED visits, stratified by triage categorization. Non-urgent visits were more likely to be younger, non-Hispanic black race, have Medicaid or no insurance (self-pay), and less likely to have Medicare. Non-urgent visits were less likely to have arrived by ambulance and less likely to have a length of stay over 3 hours. Non-urgent visits were more common in hospitals located in non-urban areas and less common in the West. Time of day and day of the week were similar across triage acuity categories.
DISCUSSION
Our findings demonstrate that most ED visits categorized as non-urgent had some diagnostic or therapeutic intervention performed during the visit. Previous studies have found a lower rate of resource utilization for non-urgent patients;(13–15) however, our analysis shows a high rate of interventions for even the lowest acuity visits. This suggests that healthcare services are needed even for the lowest acuity visit and calls into question the designation of a non-urgent ED visits as being “unnecessary.” We would argue that categorizing an ED visit as “unnecessary” depends not only on patient acuity but also the appropriateness of the site of service and availability of alternate sources of acute, unscheduled care.(7) The ED may in fact be an appropriate site of service for a non-urgent presentation or complaint if there are no other available sites to provide timely care to the patient.It is possible that some of these non-urgent patients could have had their medical needs met at a different site of service. Furthermore, clinical practice differences might lead to fewer interventions by primary care providers than are typically obtained in the ED. However, many barriers to accessing timely outpatient care have been associated with increased ED utilization.(16,17) One study found that up to 32% of non-urgent ED patients attempted to access primary care but were unsuccessful.(18) Of patients who described the ED as their usual source of care, over two thirds (68%) desired to obtain a primary care physician and nearly half (48%) tried to get one.(19)
We found that non-urgent ED visits were higher among Medicaid and self-pay visits. Not surprisingly, these are also the patients who have the most difficulty obtaining access to a primary care provider. Indeed, just over a quarter (25.5%) of primary physicians surveyed were not accepting new Medicaid patients and 22.8% were not accepting new patients without insurance.(20) In comparison, only 5.1% of primary physicians were not accepting patients with private insurance.(20) Collectively, these data suggest that although a patient may have a non-urgent condition that could be evaluated in up to 24 hours, barriers to care may predispose them to use the ED for non-urgent care.
Our analysis showed a similar rate of non-urgent visits across times of day and days of the week, with no surge of visits in off hours or on weekends. Furthermore, our results demonstrate that non-urgent ED visits occur even at times when health care clinics are open. Patients who present with non-urgent conditions often do so because they perceive a need for immediate medical attention, have been referred by their primary physician, or simply because the ED provides easier accessibility.(18,21,22) Of patients who report having a primary physician, 47% noted the ease of obtaining unscheduled care in the ED as a reason for their choice of site of service.(21) The barriers to obtaining timely care are also noted among primary physicians, 73.4% of whom stated that a lack of timely reports from other physicians or labs limited their ability to provide high quality care.(20) Many diagnostic interventions are not easily available in the outpatient setting. The ED offers a unique set of services and diagnostic capabilities in a time-efficient manner, which can expedite medical management for some patients. While the appropriateness of this clinical practice is debatable, it reflects the reality for many patient populations.
Some policymakers have advocated for the reduction of “unnecessary” ED visits as a means to generate significant savings in the healthcare system.(4) However, the estimates of potential costs associated with treatment of non-urgent visits in the ED as opposed to other sites of care are variable and the true cost-savings from a reduction in non-urgent ED visits may only be modest.(9) Some have reported that ED costs for minor health problems or non-urgent visits are as much as two to three times higher than care provided in other sites of service.(23) Yet others have found the cost for providing non-urgent care in the ED are relatively comparable to that provided in the outpatient settings.(8) Furthermore, previous studies comparing ED and outpatient costs of care only consider a single visit and do not include ancillary services in cost-value calculations,(8,24) which limit the interpretability of the comparison. In addition, the relative use of diagnostic tests, procedures, and medications in the outpatient setting, compared to the ED setting, for a comparable presentation is unknown. Thus, the high resource utilization in non-urgent ED visits reported in our study should prompt further analysis and comparison of the true costs associated with ED and outpatient care.
A small, but not insignificant number of non-urgent visits were admitted, sometimes in critical care settings. Prior single-center studies have reported admission rates up to 6.2% in non-urgent ED populations.(18,25,26) Similarly, we found an overall admission rate of 4.0% for non-urgent ED visits nationally. This highlights the limitations and difficulty with using triage acuity systems as a reliable surrogate marker to predict patient acuity and disposition including hospitalization.
LIMITATIONS
Data from the NHAMCS are subject to the limitations of general survey research, with possible errors in data collection and coding. In particular, data abstractors may have recorded incorrect or incomplete data on triage acuity levels, the type of ED services provided, and patient disposition. A recent NHAMCS study on the disposition of intubated patients in the ED has highlighted errors in data coding(27) and suggests that this may result in undercounting of ED interventions.(12) However, NHAMCS data have been used widely to report the epidemiology of a variety of characteristics and conditions, using rigorous methodology.(28)We did find that a moderate number of charts had missing data, which can be attributed to multiple factors including the lack of nursing triage systems at some hospitals, as well as general errors in coding. We found that the characteristics of the missing visits were generally similar to those charts that were included in analysis. There was a lower rate of resource utilization and a lower proportion of admissions among the visits with missing triage acuity. It is possible that these could represent more lower acuity visits, which if included in primary analysis would actually decrease the resource utilization for non-urgent visits. However, there is no explicit reason to suspect those charts with missing triage acuity would preferentially be from less acute visits. Therefore, all triage categories would be affected similarly and the missing charts are unlikely to represent a major source of bias.
Finally, this analysis relies on triage classification of acuity, which may be subject to interpretation and the expertise of the classifying practitioner and is not standardized across hospital EDs. There are multiple different methodologies for classifying level of acuity but there is no clear evidence the level would be skewed in one direction and therefore should not markedly influence the results.
CONCLUSION
Most non-urgent ED visits had some diagnostic or therapeutic
intervention. Relatively low, but notable, proportions of non-urgent ED visits
had advanced imaging or were admitted to the hospital, sometimes to a critical
care setting. These results call into question non-urgent ED visits being
broadly classified as “unnecessary,” particularly in the setting of limited
access to timely primary care for acute illness or injury.
FOOTNOTES
Conflicts of Interest: By the WestJEM article
submission agreement, all authors are required to disclose all affiliations,
funding sources and financial or management relationships that could be
perceived as potential sources of bias. The authors disclosed none.
REFERENCE
Honigman, Leah S; Wiler, Jennifer L; Rooks, Sean; & Ginde, Adit A. (2013). National Study of Non-Urgent Emergency Department Visits and Associated Resource Utilization. Western Journal of Emergency Medicine, 14(6). uciem_westjem_16112. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876304/
QUESTIONS:
1. True or False: There is no standard definition of a
non-urgent emergency department visit and estimates of the number of annual
non-urgent ED visits vary and are dependent on the nature of categorization.
2. The CDC’s
2006–2009
National Hospital Ambulatory Medical Care Survey revealed that ___% of United
States ED visits were categorized as non-urgent.
a. 10.1
b. 22.2
c. 50
d. 66.6
3. The authors of this
study hypothesized that non-urgent visits would have less intense resource
utilization than higher acuity visits, but that some non-urgent visits would
involve important ED interventions, including hospitalization.
4.
This study found that 87.8% of the non-urgent visits had some diagnostic
testing or treatment in the ED including all except which of the following:
a.
Imaging obtained
b.
Procedure performed
c.
Medication administered
d.
Work Note given
5.
This study found that ___ % of non-urgent patients ultimately required
hospitalization.
a.
1
b.
4
c.
8
d.
12
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A few weeks ago I read a front page article in the Minneapolis Star Tribune which detailed a recent state report on hospital spending and in particular the cost of "unnecessary visits" to Minnesota emergency departments. It disturbed me.
Rather than bore you with my opinion, I thought it would be worthwhile for us to look at an actual study which has evaluated emergency department utilization and, hopefully elevate the discussion to a more thoughtful level.
This Month's Journal Club Article is titled: National Study of Non-urgent Emergency Department Visits and Associated Resource Utilization
Link to blog with article: http://ecc-education.blogspot.com/2015/08/virtual-journal-club-august-2015.html
There are a couple of main points, and some other subtle points, which I think are worth noting:
-This study emphasized that "non-urgent" may not be the same as "unnecessary." It's easy to confuse the two concepts. Back pain might be considered "non-urgent" but if it's 3 in the morning and no primary provider is available, seeking immediate care might be entirely necessary.
-The American College of Emergency Physicians defines an emergency service as: "any health care service provided to evaluate and/or treat any medical condition such that a prudent layperson possessing an average knowledge of medicine and health, believes that immediate unscheduled medical care is required." (Remember that we are far above average when it comes to understanding this concept, our patients "health literacy" varies greatly from ours.)
-It's not always easy to determine what is "non-ugent" and there is quite a bit of variability even among those triaging (Nurses/EMS) who try to assign such terminology. That inherently makes emergency department utilizaiton a hard thing to study and there is quite a bit of variability seen when comparing studies.
-It's one thing to look back retrospectively at insurance claims data and say x% of patients did not need to be seen in the ED. This is a retrospective analysis and time is on your side. It's an entirely different thing, however, to prospectively say that someone doesn't need to be seen in the emergency department in real time. There is no crystal ball. Studies suggest that at least some percentage of those termed "non-urgent" end up hospitalized. Retrospective analysis is very limited. Real time matters.
-Access to primary care is often limited for any number of reasons: insurance, time of day, overbooked primary care appointments, and a shortage of primary care providers. Lack of access might be the bigger issue when it comes to "unnecessary" ED Visits.
-For better or worse our society has created a safety net (EMTALA) and said that Emergency Departments must see anyone who walks in the door..at anytime...for anything. No other area of medicine carries that charge. There are bound to be misinterpretations and even abuse of this open resource. But, what is the alternative?
-Cost: Excluding costs to insurance companies, what are the actual costs to society or the healthcare system for these "unnecessary" emergency department visits? How many resources does a non-urgent visit demand and does it really distract that from more urgent medical care? The Agency for Healthcare Research and Quality and the Department Health and Human Services estimates emergency care costs about 2 percent of the total US health care dollar. Therefore, doesn't it seem reasonable to conclude that the cost for the "unnecessary emergency department visit" is a fraction of that 2 percent?
Ultimately, this topic hits home for most of us. There is a lot we could talk about. I hope this article sheds some light (or at least opens the door) to more thoughtful conversation about emergency department utilization and our response to this controversial issue.
Thanks and see you next month.
-Tom
Thomas Horejsi MD
Education Tsar
Emergency Care Consultants
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