Comparison of Presenting Complaint vs Discharge Diagnosis for Identifying “ Nonemergency” Emergency Department Visits

Abstract

ITH INCREASING MEDIcal care costs, policymakers have turned to emergency department (ED) utilization as a potential source for cost savings. Although the assumptions driving this policy approach are unproven, 1 recent attempts to reduce ED use have occurred in Medicaid programs. [2][3][4][5][6] If implemented for patients in Medicaid programs, it is likely that such practices may result in similar policies by other payers, potentially affecting access to ED care for other segments of the population.One approach aimed at reducing ED use has been to deny or limit payment if the patient's diagnosis on discharge from the ED appears to reflect a "nonemergency" condition. 3,7,8 Legislatures or regulators in Tennessee, Iowa, New Hampshire, and Illinois have considered or enacted legislation or regulations that would limit payment for nonemergency ED visits by Medicaid enrollees, based on discharge diagnosis. Other states, including Arizona, Oregon, Illinois, Iowa, Nebraska, North Carolina, and New Mexico, have recently implemented or considered implementing some level of copayment requirement for nonemer-For editorial comment see p 1173.

Predictors of Low-Acuity Emergency Department Use by Patients Enrolled in a Family Health Team

“…11 Another study examined reasons for patient presentation to the ED in Edmonton, Alberta. 12 The study found that many patients made concerted efforts to avoid ED visits; 61% of patients sought alternative care before visiting the ED. 12 The role of health professionals and systems in driving ED overuse must be considered.…”

“…12 The study found that many patients made concerted efforts to avoid ED visits; 61% of patients sought alternative care before visiting the ED. 12 The role of health professionals and systems in driving ED overuse must be considered. Strikingly, 47% of patients who sought alternatives to the ED made contact with a physician's office.…”

“…Much discussion in the literature has focused on trying to identify patients with low-acuity presenting complaints to see if they might be safely diverted away from the ED. [11][12][13][14] A recent study demonstrated limited concordance between presenting complaints and ED discharge diagnoses, suggesting that presenting complaints are unable to accurately identify non-emergent ED use. 11 The study found that only 6.3% of patients presenting to the ED had primary care-treatable diagnoses based on discharge diagnosis and an algorithm.…”

“…Strikingly, 47% of patients who sought alternatives to the ED made contact with a physician's office. 12 Patients who called a physician's office were directed to visit a family physician (3%), a health care professional (9%), or the ED (63%). The study also found that 14% of patients contacted a regional health line.…”

“…The study also found that 14% of patients contacted a regional health line. 12 One study found regional health lines recommended going to the ED (58%), seeing a primary care physician (6%), or seeing another health care professional (3%). 3 Patients who called a physician's office or regional health line were almost ten times more likely to be directed to visit the ED than a family physician.…”