How Many ER Visits Can Actually Be Avoided?

Emergency room use is often singled out as an area for utilization and spending reductions.  The perception is that many of the visits are avoidable or unnecessary and that they may reflect on poor access or inadequate primary care.  A study in the International Journal for Quality in Health Care examines how much ER use is actually unnecessary.   (IJQHC Study)   Of course, the first problem is trying to define “unnecessary” or “avoidable”.  Prior research used things like retrospective diagnoses, whether a hospital admission occurred, triage scores, and patient-reported data.  All have issues.  These researchers created a definition of avoidable as being an ER visit that resulted in no diagnostic tests, procedures or medication being prescribed, which is a very restrictive definition.  They then looked at national ambulatory survey data on adults aged 18 to 64 from the years 2005-2011.  (As an aside, it is hard to understand why these studies use such old data.  It would be nice for this study in particular to have more recent information, given that the ACA expansion basically occurred during and after this time period.)

A total of 442 million ER visits were examined.  Only 3.3% met the definition of avoidable.  For these visits, the average patient age was 36, 52% were female, 70% were Caucasian, 33% had private insurance, 22% were on Medicaid, 28% were uninsured and 14% arrived by ambulance.  The top 5 complaints were toothache, back pain, headache, psychosis symptoms and sore throat.  Alcoholism and dental diagnoses were prevalent.  Note that almost none of these require an ER and ER clinicians aren’t trained to handle these matters.  While these researchers find a low rate of avoidable visits, their definition seems far too restrictive.  Out of the 442 million visits, half had no procedure, over a quarter had no diagnostic testing and about 14% did not result in a prescription for medication.  That suggests a much higher rate of problems that could have been handled the next day at a primary care provider or even at urgent care or a retail clinic.  Looks like people are showing up at the ER and basically being told take two aspirin and go home.