Only 3.3% of ED Visits 'Avoidable'

The top three non-emergent ER diagnoses were identified by researchers as joint disorders, atopic dermatitis, and other soft tissue diseases.

What does “avoidable” mean?

Answer: It depends on who’s doing the study.

A study published Thursday in the peer-reviewed International Journal for Quality in Health Care found that only 3.3% of emergency room visits could be classified as “avoidable.” That stands in stark contrast, for example, with another study from Truven Health Analytics that found nearly 71% of emergency room visits are avoidable. What gives?

For its part, the more recent study, Avoidable Emergency Department Visits: A Starting Point, contends that it’s difficult to determine whether an ED visit was necessary until after the visit, which makes some sense, but severely limits the ability of triage to make a difference.

“Using chief complaints derived from diagnoses, which are determined post hoc, can be dangerous because visits that are eventually determined to be non-emergent after physician examination and diagnostic testing are virtually indistinguishable from emergent visits,” the study says.  

So there’s that.

The 3.3% of visits the study’s authors do contend are actually avoidable include visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home, which is fairly restrictive. Further, a significant number of those avoidable visits, by their definition, included mental health and dental conditions, which emergency departments are ill-equipped to treat.

“This suggests a lack of access to healthcare rather than intentional inappropriate use is driving many of these ‘avoidable’ visits,” said study author Renee Hsia, MD, of the Department of Emergency Medicine at the University of California, San Francisco, in a press release. “These patients come to the ER because they need help and literally have no place else to go.”

To derive their results, study authors examined a total of 115,081 records, representing 424 million ED visits made by patients aged 18–64 years who were seen in the ED and discharged home.

By contrast, a separate study, which used data from emergency department visits of patients with employer-sponsored health plans, and examined insurance claims data for more than 6.5 million emergency room visits made by commercially insured individuals, under age 65, in calendar year 2010, found that just 29% of those patients required immediate attention in the emergency room.

The Truven study found that the top three non-emergent diagnoses were joint disorders, atopic dermatitis, and other soft tissue diseases.

Part of the controversy surrounding ED visits is, unsurprisingly, about money. ED care is expensive compared to non-emergency settings, and not only do insurance companies have an incentive to reduce unnecessary visits in favor of lower-cost settings of care, but with the rise of high deductible health plans, so do many patients. That is especially true for patients with employer-sponsored high-deductible plans, where the patient is responsible for all medical care costs up to a certain deductible, usually several thousand dollars, in a calendar year.

Medicaid patients, to use one example, do not generally have the same cost-sharing responsibilities, although that is changing.