Only 3.3% of ED visits are avoidable

Health systems looking to limit overutilization of healthcare services may not find much to combat in the emergency department (ED), where only 3.3 percent of visits between 2005 and 2011 were classified as “avoidable,” according to a study published in the International Journal for Quality in Health Care.

The study, led by Renee Hsia, MD, MS, emergency medicine professor at the University of California, San Francisco, examined data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011, representing 424 million ED visits. Researchers defined “avoidable” visits as those which didn’t require any diagnostic or screening services, like imaging or blood tests, as well as no procedures or medications and where patients were discharged back to their homes. It left out visits where the procedures were left blank or where the patient left the ED before being seen.”

Using this standard—which Hsia and her coauthors called a “very conservative definition”—only 3.3 percent of all visits could be classified as “avoidable,” about 14.1 million in total. The top complaints for these visits were toothache, back pain, headache, other symptoms/problems related to psychosis and throat soreness. In ICD-9 codes, the top three diagnoses of “avoidable” visits were alcohol abuse, dental disorders and depression. Alcohol-related and mood disorders accounted for the greatest share of these visits at 6.8 percent.

“Our most striking finding is that a significant number of avoidable visits are for conditions the ED is not equipped to treat,” wrote Hsia and her coauthors. “Emergency physicians are trained to treat life- and limb-threatening emergencies, making it inefficient for patients with mental health, substance abuse, or dental disorders to be treated in this setting. One potential mechanism to more appropriately direct limited healthcare resources could be to increase access to mental health and dental care, which have traditionally been treated as separate categories of healthcare.”

The study did have several limitations. Most notably, the authors admitted its definition of avoidable visits overestimates the number of patients receiving no tests, procedures or medications because the survey doesn’t code some minor procedures. They noted other studies had different definitions and thus very different results, with some estimating as many as 70 percent of ED visits could be more suitably treated in a primary care setting.

The research was not funded by the American College of Emergency Physicians (ACEP), but the group did spotlight the results in a press release, saying even for the conditions making up the greatest shares of avoidable visits, most patients in those situations still needed some form of treatment.

"Despite a relentless campaign by the insurance industry to mislead policymakers and the public into believing that many ER visits are avoidable, the facts say otherwise," said ACEP President Becky Parker, MD. "Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about 'unnecessary' ER visits are just that – myths."

In an effort to discourage patients from going to an ED for issues more appropriately served by a primary care physician, a few insurers, like Blue Cross and Blue Shield of Georgia, have said they won’t cover ED visits for conditions it later deems as non-urgent. Emergency physicians have harshly criticized those policies, saying it would instead discourage patients from going to the ED at all for fear of receiving a hefty hospital bill.