Only 3% of ED visits are avoidable? Maybe only when using the most restrictive of definitions

Sept. 29, 2017 / By L. Gordon Moore, MD

We have lots of opportunities to improve primary care access so that people have a viable alternative to an ED visit for non-emergent care. As anyone who has ever worked in an emergency room can tell you, it takes little effort to identify instances where a person might have been better served by their primary care physician (PCP). 

There are many potential causes behind this rate. A person may have been frightened by the severity of symptoms, their PCP’s office might direct after-hours care to an ED, there may be a lack of accessible primary care, to name a few potential causes.

Improving this rate likely requires sophisticated coordination of efforts by many parts of a healthcare delivery system to bridge many gaps in accessibility (e.g. after-hours appointments, on-call systems, location of new primary care capacity relative to needs). Solving these problems could reduce the rate by which people turn to an emergency department for care they could receive in a PCP’s office. Trying to solve this problem after the person has already shown up in the ED is likely to be more difficult.  Aside from setting up a primary care clinic within the ED, it’s tough to tell someone that they should have gone to their PCP first without creating resentment and resistance.

I wonder if this is why Hsia and Niedzwiecki chose to define “avoidable” this way in their study:

“We conservatively defined “avoidable” ED visits as discharged ED visits not requiring any diagnostic tests, procedures or medications. Diagnostic tests included imaging (x-rays, CT scans, MRI), blood tests (CBC, BUN/creatinine, electrolytes) or other tests (cardiac monitor, EKG/ECG, toxicology). Procedures included IV fluids, suturing/staples and nebulizer therapy. Medications included over-the-counter and prescription medications administered or prescribed.

We excluded patients admitted for observation, hospitalized, transferred, died in the ED or were dead on arrival.”^[1]

A predictable outcome of this study are headlines like this:

Only 3% of emergency room visits may truly be avoidable, study suggests^[2]

One might be justified in presuming that we should focus elsewhere to find opportunities to improve population health outcomes, if not for significant amount of data suggesting that this definition is overly restrictive and misses significant opportunities for improvement. Consider these scenarios that would not be avoidable by this definition:

• Going to the ED to have a cast removed, sutures taken out, routine blood draw for chronic condition management
• An ED visit for an acetaminophen prescription, an influenza vaccination
• Anyone seen for a common cold who then had a chest X-ray to allay the ED’s concern that they might miss something like lung cancer or a pneumothorax
• A person who goes to the emergency department multiple times each month for treatment of migraine headaches

AHRQ describes care coordination opportunities to address potentially preventable emergency department visits. Between 13-27 percent of ED visits could be cared for in urgent care or retail clinics according to one study.^[3]

A visit to the emergency department is not a pleasant experience for most people. Many if not most people with non-emergent needs would rather have been cared for by their PCP if they had timely access to a PCP who could provide for most of their needs. Using a less restrictive definition of potentially preventable ED visits could help a health system recognize an opportunity to assess deficiencies in primary care access. With geo-tagging software, it is possible to specific data to identify locations that could meet these needs.^[4] 

L. Gordon Moore, MD, is senior medical director for Populations and Payment Solutions at 3M Health Information Systems.

What’s one of the most untapped resources in health care and how can we leverage it? Watch this video.

[1] Hsia, Renee Y., and Matthew Niedzwiecki. “Avoidable Emergency Department Visits: A Starting Point.” International Journal for Quality in Health Care, n.d., 1–4. doi:10.1093/intqhc/mzx081.

[2] “Only 3% of Emergency Room Visits May Truly Be Avoidable, Study Suggests | FierceHealthcare.” Accessed September 26, 2017. /healthcare/just-3-er-visits-may-truly-be-avoidable-study-suggests.

[3] Weinick, Robin M., Rachel M. Burns, and Ateev Mehrotra. “How Many Emergency Department Visits Could Be Managed at Urgent Care Centers and Retail Clinics?” Health Affairs (Project Hope) 29, no. 9 (September 2010): 1630–36. doi:10.1377/hlthaff.2009.0748.

[4] Weber, Ellen J., Jonathan A. Showstack, Kelly A. Hunt, David C. Colby, and Michael L. Callaham. “Does Lack of a Usual Source of Care or Health Insurance Increase the Likelihood of an Emergency Department Visit? Results of a National Population-Based Study.” Annals of Emergency Medicine 45, no. 1 (January 2005): 4–12. doi:10.1016/j.annemergmed.2004.06.023.