State of the State: Avoidable ER Visits

In his 2014 State of the State’s Health address to state lawmakers, the director of the Rhode Island Department of Health commented, “44% of all the emergency department visits in the state are preventable.” Unfortunately, I think these comments reflect a growing public perception of emergency medicine – that a large percentage of people use the ED inappropriately and as an expensive substitute for primary care.

As a practicing emergency physician and a health services researcher at Brown, I can tell you that this view of the ED is inaccurate and misleading.  Rhode Island’s Department of Health bases their calculations of “avoidable visits” on a flawed classification algorithm that is based solely on discharge diagnoses.  Academic studies (such as this one in the Journal of the American Medical Association) have shown that discharge diagnoses are an extremely poor predictor of the actual urgency of a patient’s visit, compared to information such as the patient’s chef complaint or the initial assessment made when the patient is triaged in the ED.

To give an example, suppose you had crushing chest pain and go to the ED rather than your primary care doctor out of concern that you might be having a heart attack.  After you are seen and go through a series of tests, it may turn out that in the end, you didn’t have a heart attack (thank goodness) but instead it was severe heartburn.   A visit like this will be classified by the Department of Health’s algorithm as “non-emergent” or “avoidable” even though the reason you went was because you thought you had a life-threatening condition. I can’t think of any physician, primary care or otherwise, that would consider this an inappropriate use of the ED.

There are definitely ED visits that I think are “avoidable,” but by and large, I think those visits are more likely due to poor access to care rather than poor judgment on the part of the patient. Multiple academic studies have shown this. For example, this study of Medicaid patients concluded that the majority of patients come for emergent issues, and only about 10% are “non-urgent.”

Our state does need to expand access to primary care and I’m a big supporter of the Department of Health’s efforts to encourage the establishment of patient centered medical homes. However, the motivating factor behind this effort should be to promote better disease management of chronic conditions and better population health, rather than seeking to reduce inappropriate ED visits.

By Michael Lee, MD (@ERcosthacker)

Michael Lee is Assistant Professor of Emergency Medicine at the Alpert Medical School of Brown University and a researcher with a focus on economics and financing of emergency care and health policy.

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