This article presents a systematic review of the US literature on factors influencing the decision to visit the emergency department for nonurgent conditions.
Published Online: January 22, 2013
Lori Uscher-Pines, PhD, MSc; Jesse Pines, MD, MBA; Arthur Kellermann, MD, MPH; Emily Gillen, MA; and Ateev Mehrotra, MD, MS
Background: A large proportion of all emergency department (ED) visits in the United States are for nonurgent conditions. Use of the ED for nonurgent conditions may lead to excessive healthcare spending, unnecessary testing and treatment, and weaker patient–primary care provider relationships.
Objectives: To understand the factors influencing an individual’s decision to visit an ED for a nonurgent condition.
Methods: We conducted a systematic literature review of the US literature. Multiple databases were searched for US studies published after 1990 that assessed factors associated with nonurgent ED use. Based on those results we developed a conceptual framework.
Results: A total of 26 articles met inclusion criteria. No 2 articles used the same exact definition of nonurgent visits. Across the relevant articles, the average fraction of all ED visits that were judged to be nonurgent (whether prospectively at triage or retrospectively following ED evaluation) was 37% (range 8%-62%). Articles were heterogeneous with respect to study design, population, comparison group, and nonurgent definition. The limited evidence suggests that younger age, convenience of the ED compared with alternatives, referral to the ED by a physician, and negative perceptions about alternatives such as primary care providers all play a role in driving nonurgent ED use.
Conclusions: Our structured overview of the literature and conceptual framework can help to inform future research and the development of evidence-based interventions to reduce nonurgent ED use.
(Am J Manag Care. 2013;19(1):47-59)
Articles on nonurgent emergency department (ED) use are heterogeneous with respect to study design, population, comparison group, and nonurgent definition.
The limited evidence suggests that younger age, convenience of the ED compared with alternatives, referral to the ED by a physician, and negative perceptions about alternatives such as primary care providers all play a role in driving nonurgent ED use.
Efforts to deter nonurgent ED use can produce unintended consequences that must be considered.
Future studies would benefit from the use of a robust theoretical framework on what drives nonurgent ED use.
Nonurgent emergency department (ED) visits are typically defined as visits for conditions for which a delay of several hours would not increase the likelihood of an adverse outcome.1,2 Most studies find that at least 30% of all ED visits in the United States are nonurgent, although select studies such as those using National Hospital Ambulatory Medical Survey data report lower percentages (<10%).3-8 Visiting the ED instead of another care site (eg, physician’s office, retail clinic, urgent care) for a nonurgent condition may lead to excessive healthcare spending and unnecessary testing and treatment, and represent a missed opportunity to promote longitudinal relationships with primary care physicians (PCPs).4-6,9-12 A recent study projected $4.4 billion in annual savings if nonurgent ED visits were cared for in retail clinics or urgent care centers during the hours these facilities are open.13 With increasing demand and a shortage of PCPs, nonurgent ED use will likely increase in the near future. Recent predictions suggest that implementation of the Affordable Care Act and resulting expansions of insurance coverage will contribute to even higher levels of ED usage.14,15
There is widespread interest in interventions to discourage nonurgent ED visits. A 2006 survey found that 30% of emergency physicians work in hospitals that have implemented practices to discourage nonurgent visits.16 Interventions by health systems and payers have included patient education on what is appropriate ED use, financial disincentives such as higher copayments for ED visits, and encouragement of PCPs to provide care on evenings and weekends.17-19 Despite these efforts, nonurgent ED visits have continued to rise.20 One explanation could be that prior interventions have not adequately addressed the underlying issues that lead patients to visit EDs for nonurgent conditions.7 Moreover, policies to deter ED use can have negative, unintended consequences. For example, enrollees in high-deductible health plans, who bear a higher share of the costs of an ED visit, are less likely to seek care for a true emergency.21 Nonurgent ED use has been discussed in the peer-reviewed literature for the last 3 decades.12 However, no systematic review of nonurgent ED use in the United States has been published to date.
We conducted a systematic review of the literature and developed a conceptual framework to understand why individuals visit the ED for nonurgent conditions. Our goal was to highlight gaps in knowledge, inform future research on this topic, and empirically inform future interventions that attempt to decrease the number of nonurgent ED visits.
We conducted a systematic review of the peer-reviewed and grey literature to identify factors associated with nonurgent ED use by adults in the United States. Studies outside the United States were excluded because they may not generalize to the unique features of the US healthcare system.22 A health sciences research librarian worked with the study team to develop our search strategy. We searched multiple databases including Cumulative Index to Nursing and Allied Health (CINAHL), OAIster, ISI Web of Science, New York Academy of Medicine Grey Literature database, PsycINFO, and PubMed. Searches used the following free text and medical subject headings terms: (emergency service, hospital OR emergency room, OR emergency department) AND (nonurgent OR nonurgent OR unnecessary OR inappropriate). We also used the “related citations” function in PubMed to identify any articles determined to be similar to articles selected for inclusion, and we hand-searched the reference lists of all included articles. The search for abstracts was conducted in January 2011.
Two reviewers (LU-P and EG) independently examined each abstract returned by the PubMed search, and 1 reviewer (LU-P) reviewed the abstracts returned by the other search engines (fewer than 10% of the total abstracts reviewed). If either or both reviewers determined that an abstract met inclusion criteria, it underwent a more thorough full-text review. One reviewer (LU-P) evaluated the full-text articles on whether they met inclusion criteria and extracted data on all included articles. To meet inclusion criteria, articles had to be published after January 1990, be written in English, and present some quantitative data (including descriptive data) on nonurgent ED use. We excluded dissertations, articles without abstracts, and articles exclusively focused on pediatric or non-US populations. Articles that presented qualitative data only or reviewed existing literature were not formally included in the review, but were used to inform the creation of a conceptual framework.5,6,22-31
To facilitate data extraction, we created a standardized data form to collect information from included articles. The information gathered, as available, included study population, sample size, setting, design, comparison group, response rate, definition of a nonurgent visit, independent and dependent variables, key findings, and use of a conceptual framework. A variety of terms were used to describe nonurgent visits including inappropriate visits,32 avoidable visits,16 nonemergency visits,33 and minor illness visits.34 In this article we chose the most prevalent term: nonurgent visits. The research team elected not to rate the quality of articles because all the studies were observational in nature and the majority did not use multivariate statistics.
Identification of Relevant Articles
The initial search strategy generated 1983 abstracts. An additional 7 abstracts were obtained by hand-searching the reference lists of full-text articles and using the related citations feature in PubMed. From this list, the reviewers identified 63 articles for full-text review, of which 26 satisfied criteria for inclusion (Figure 1). The primary reasons for exclusion included lack of quantitative data and an exclusive focus on non-US patients.
Overview of Articles and Definition of Nonurgent Condition
Six studies (23%) described only visits for nonurgent connditions (Table 13,9,33,35-37). Of those, 4 articles (16%) described nonurgent visits to the ED and 2 articles (8%) compared nonurgent ED visits with PCP visits for similar conditions.33,37 The other 20 articles (77%) compared nonurgent ED visits with other types of ED visits (Table 21,2,12,16,32,34,38-51), including urgent visits, urgent and emergent visits,1,47 and all ED visits.16,34
No 2 studies used the same exact definition of nonurgent visits. A total of 11 articles (42%) identified nonurgent visits through retrospective review of medical records, 11 (42%) identified nonurgent visits prospectively at triage, and 3 articles (12%) used retrospective patient self-report. (See eAppendix at www.ajmc.com for additional detail on definitions.) Across the relevant articles, the average fraction of all ED visits that were judged to be nonurgent (whether prospectively at triage or retrospectively following ED evaluation) was 37% (range 8%-62%). Four articles (15%) presented a conceptual framework to guide the study design and interpretation of results. Three articles used the Anderson model of healthcare utilization,12,33,35 and 1 article used Mechanic’s model of illness behavior.47
In the reminder of this article, we summarize findings from the subset of articles (n = 16) that included a comparison group of either urgent ED patients or all ED patients and examined whether differences among these groups were statistically significant. We also include illustrative examples from the remaining studies (n = 10) regarding self-reported reasons for nonurgent ED use and barriers to use of alternative locations.
Factors Associated With Nonurgent Emergency Department Use
We summarize our findings on sociodemographic factors and other factors associated with nonurgent ED use in Table 3 and Table 4, respectively. These factors are discussed below.
Age. Among the 9 articles that examined age, 6 found that younger adults were more likely to have nonurgent visits compared with older adults.32,41,46,48,50,51 Effect sizes were generally large (odds ratio [OR] >2). Three articles found no association between nonurgent ED use and age.12,34,45
Race. Among the 9 articles that examined race, 4 articles found that blacks were more likely than whites to have a nonurgent visit.12,42,46,51 However, 5 articles reported no association.16,34,45,48,50 One study pointed out that blacks had higher rates of nonurgent ED visits despite the fact that they were less likely to utilize healthcare in general.12
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