As healthcare spending in the United States continues to rise substantially each year, policymakers have advocated for strategies to reduce what they deem as “unnecessary” ED visits as a way to generate cost savings. “When patients come to the ED and are classified at triage as non-urgent, payers often consider these visits unnecessary,” explains Adit A. Ginde, MD, MPH. “It has been argued that similar medical services could be provided at different sites of care, perhaps at a lower cost. The problem is that we don’t have an adequate definition of what constitutes non-urgent visits.”
An In-Depth Analysis
Some studies indicate that nearly one-third of ED visits could be classified as non-urgent. However, few studies in the current literature describe the resource needs and disposition of patients presenting to EDs with non-urgent triage acuity. To address this research gap, Dr. Ginde and colleagues published a study in the Western Journal of Emergency Medicine that used retrospectively analyzed data from the 2006-2009 National Hospital Ambulatory Medical Care Survey. These data were used to compare resource utilization of ED visits that were characterized as non-urgent at triage with visits in which there were higher triage acuity levels. Resource utilization included factors such as diagnostic testing, treatment, and hospitalization within each acuity categorization.
“One of our key findings was that about 10% of ED visits in the U.S. were categorized as non-urgent,” says Dr. Ginde. “That means that about 13 million of the 130 million annual ED visits each year may be considered non-urgent.” However, most non-urgent visits (nearly 88%) had at least one intervention in the ED, which included imaging, diagnostic or screening services, a procedure performed, or medication administered (Table 1). The actual number of imaging, procedures, and medications administered in the non-urgent group was significant, according to Dr. Ginde.
The study also characterized patients with non-urgent visits who required hospital admission and compared them with patients who were not admitted (Table 2). For visits that were considered non-urgent, hospital admission was more likely among older patients and those who were Caucasians, insured by Medicare, and arrived by ambulance. Non-urgent patients who were less likely to be admitted included those on Medicaid and self-pay visits. This was an expected finding because these patients typically have the most difficulty obtaining access to primary care providers. This is particularly salient and timely considering the recent Medicaid expansion and the adoption of the Affordable Care Act.
Questioning “Unnecessary” Designations
Most non-urgent ED visits had some diagnostic or therapeutic intervention performed during the visit, Dr. Ginde says. “We also found that there was a high rate of interventions for even the lowest acuity visits, suggesting that healthcare services are needed even for the lowest acuity visits,” he says. “This calls into question the designation of a non-urgent ED visit as being unnecessary.” He adds that categorizing an ED visit as unnecessary should depend on patient acuity as well as the appropriateness of the site of service and availability of alternate sources of acute, unscheduled care. “In many cases,” Dr. Ginde says, “barriers to care may predispose patients to using the ED for non-urgent care.”
Patients who present to EDs with non-urgent conditions often do so because they believe they need immediate medical attention, have been referred there by their primary physicians, or because the ED provides accessible services. “In some cases, there may be no other sites available to provide timely care,” Dr. Ginde says. “For these cases, the ED may actually be the appropriate site of service for these ‘non-urgent’ visits. In addition, many diagnostic interventions or procedures are not easily available in outpatient settings.” He says that EDs offer a unique set of services and diagnostic capabilities in a timely manner, which in turn can expedite medical care for some patients. While the appropriateness of this practice may be debated, it reflects the reality for many patients.
More Research Warranted
Previous studies have reported that ED costs for minor health problems or non-urgent visits can be two to three times higher than costs of care provided at other sites of service. Others have suggested that the costs of providing non-urgent care in the ED are relatively comparable to those of care given in outpatient settings. The high resource utilization in non-urgent ED visits reported in the study should prompt more studies on this issue, according to Dr. Ginde. Comparisons are needed to explore the true costs associated with ED and outpatient care for non-urgent visits before measures are taken by policymakers to reduce what they consider unnecessary ED visits in an effort to save costs.
Readings & Resources (click to view)
Honigman LS, Wiler JL, Rooks S, Ginde AA. National study of non-urgent emergency department visits and associated resource utilization. Western J Emerg Med. 2013;14:609-616. Available at: http://escholarship.org/uc/item/1k92g70r.
Durand AC, Gentile S, Devictor B, et al. ED patients: how nonurgent are they? Systematic review of the emergency medicine literature. Am J Emerg Med. 2011;29:333-345.
Cheung PT, Wiler JL, Ginde AA. Changes in barriers to primary care and emergency department utilization. Arch Intern Med. 2011;171:1397-1399.
Afilalo J, Marinovich A, Afilalo M, et al. Nonurgent emergency department patient characteristics and barriers to primary care. Acad Emerg Med. 2004;11:1302-1310.
Northington WE, Brice JH, Zou B. Use of an emergency department by nonurgent patients. Am J Emerg Med. 2005;23:131-137.
Baker LC, Baker LS. Excess cost of emergency department visits for nonurgent care. Health Aff. 1994;13:162-171.