A decrease in access to EDs throughout the United States has strained the healthcare system significantly. When patients leave the ED without being seen, the emergency care delivery system has failed to provide care to individuals who are in greatest need. Studies have shown that left without being seen (LWBS) visits are a marker of ED crowding and have been associated with longer waits. “The number of LWBS visits has increased dramatically in the past 15 years,” says Renee Y. Hsia, MD, MSc. “This is a reflection of mounting strains on the U.S. emergency care system.”

Regardless of the cause—be it longer wait times, increased visits, or decreased supply—patients who leave the ED without being seen signal that access-to-care issues are prevalent. “Previous studies examining LWBS have provided data on patient- level and operational determinants at single hospitals,” explains Dr. Hsia. “There is a need, however, to broaden the scope of what is known about LWBS from a larger perspective rather than in a single-hospital setting.” Little is known about variation in the amount of LWBS or about hospital-level determinants. Contemporary attempts to study LWBS have been limited by the scarcity of data reporting it. Due to a lack of information, the ability of policymakers to understand the effect of crowding on vulnerable communities and to design system-level interventions to improve access to emergency care has been hindered.

New Leaving Without Being Seen Data

A study published in the July 2011 Annals of Emergency Medicine performed a cross-sectional analysis of 262 acute-care hospitals involving more than 9 million ED visits to hospitals in California that operated an ED in 2007 to assess patient-level and hospital-level characteristics associated with LWBS. It found that the percentage of LWBS varied greatly, ranging from about 0.1% in some locations to a startling 20.3% in one hospital. The median percentage of LWBS was 2.6%. “While on the surface this figure may seem small, it’s important to note that national estimates of LWBS in the recent past were reported to be about 1.0%,” Dr. Hsia says. “These findings suggest that the phenomenon of LWBS is worsening.”

Decreased access—together with healthcare system factors and increased pressures for faster ED throughput—are important elements when considering interventions to address increasing rates of LWBS.

— Renee Y. Hsia, MD, MSc

When further examining data from the analysis, hospitals with a higher proportion of poorly insured residents experienced a higher probability of LWBS. EDs serving patients who reside in areas with higher incomes were associated with a lower probability of LWBS with each $10,000 increase in income. When hospital structural features were added to hospital socioeconomic status case mix measures, county-owned facilities, teaching hospitals, and trauma centers experienced a much higher rate of LWBS, suggesting that hospital-level insurance profiles appear to be associated with structural characteristics (Table 1). For hospitals serving areas at the lowest 10th percentile of income, the LWBS rate was 3.4%, compared with 1.7% in hospitals serving populations at the 90th income percentile (Table 2).

Interpreting the LWBS Data

The study by Dr. Hsia and colleagues illustrates how the current healthcare market is failing to serve vulnerable patients appropriately, particularly those who live in lower-income areas or are poorly insured. “Long wait times, ED capacity, and the number of patients in the waiting room have been identified as predictors of LWBS in previous analyses,” explains Dr. Hsia. “While these factors undoubtedly play a role, it’s crucial to also consider the socioeconomic and structural factors.” From 1999 to 2009, approximately 27% of EDs in the U.S. closed their doors to the public. During that same timeframe, the nation saw a 40% increase in the use of EDs by Americans. “Decreased access—together with healthcare system factors and increased pressures for faster ED throughput—are important elements when considering interventions to address increasing rates of LWBS,” says Dr. Hsia. “Real action and resources are necessary to address these disparities, especially on a systems level.”

Several systems-level interventions have been suggested to address the issue of LWBS. Conducting workflow analyses, for example, can help to identify specific reasons behind increased LBWS rates. Targeting at-risk hospitals for improved funding and reimbursement is also paramount. “Another possibility is to integrate LWBS as an avoidable outcome or patient safety measure,” adds Dr. Hsia. “But this must be done cautiously. Decision-makers need to avoid potentially unintended consequences of penalizing hospitals that serve vulnerable populations. Any actions that are taken must be done in the context of ensuring long-term success so that already struggling hospitals can survive.”


Hsia RY, Asch SM, Weiss RE, et al. Hospital determinants of emergency department left without being seen rates. Ann Emerg Med. 2011;58:24-32. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3126631/?tool=pubmed.

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