Lori Uscher-Pines, PhD, MSc

 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.

To understand the factors influencing an individual’s decision to visit an ED for a nonurgent condition.

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.

 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.

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.

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.

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%).

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).

 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.

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.

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.

 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.

 Despite these efforts, nonurgent ED visits have continued to rise.

One explanation could be that prior interventions have not adequately addressed the underlying issues that lead patients to visit EDs for nonurgent conditions.

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.

 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.

 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.

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 

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.

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 (

). 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 (

). 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.

 The other 20 articles (77%) compared nonurgent ED visits with other types of ED visits (

), including urgent visits, urgent and emergent visits,

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, 

(42%) identified nonurgent visits prospectively at triage, and 3 articles (12%) used retrospective patient self-report. (See 

 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,

and 1 article used Mechanic’s model of illness  behavior.

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 

, respectively. These factors are discussed below.

 Among the 9 articles that examined age, 6 found that younger adults were more likely to have nonurgent visits compared with older adults.

 Effect sizes were generally large (odds ratio [OR] >2). Three articles found no association between nonurgent ED use and age.

Among the 9 articles that examined race, 4 articles found that blacks were more likely than whites to have a nonurgent visit.

However, 5 articles reported no association.

 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.

Findings were inconsistent across the 10 articles that examined gender. Four articles found that women were more likely than men to have a nonurgent visit,

and 2 articles concluded the opposite (ie, men were more likely than women to have a nonurgent visit).

Among the 4 articles that assessed income,

 2 reported that persons with low incomes were more likely to have nonurgent ED visits.

Effect sizes were generally moderate (OR <2).

 Among the 13 articles that examined the uninsured, 2 found that uninsured patients were less likely to use the ED for nonurgent visits,

 2 found that the uninsured were more likely to use the ED for nonurgent visits,

 One study found that the uninsured were more likely than HMO patients but less likely than Medicaid patients to have a nonurgent ED visit.44 Articles that looked at Medicaid patients found that either Medicaid was predictive of nonurgent ED use

 Effect sizes were generally moderate (OR <2).

The only social support measure reported in the literature was marital status. Among the 4 articles that looked at the relationship between nonurgent ED use and marital status, no article identified an association.

Articles

This article presents a systematic review of the US literature on factors influencing the decision to visit the emergency department for nonurgent conditions.                                             

Emergency Department Visits for Nonurgent Conditions: Systematic Literature Review

Increasing healthcare costs have created an emphasis on improving value, defined as how invested time, money, and resources improve health. The role of emergency departments (EDs) within value-driven health systems is still undetermined. Often questioned is the value of an ED visit for conditions that could be reasonably treated elsewhere such as office-based, urgent, and retail clinics. This paper presents a conceptual approach to assess the value of these low-acuity visits. It adapts an existing analytic model to highlight specific factors that impact key stakeholders’ (patients, insurers, and society) assessments of the value of ED-based care compared with care in alternative settings. These factors are presented in 3 equations, 1 for each stakeholder, emphasizing how tangible and intangible benefits of care weigh against direct and indirect costs and how each perspective influences value. Aligning value among groups could allow stakeholders to influence each other and could guide rational change in the delivery of acute medical care for low-acuity conditions.

By adapting an existing analytic model, this paper highlights how key stakeholders (patients, insurers, and society) assess low-acuity medical care, and suggests the following:

		The value of using the emergency department for low-acuity visits depends on perspective taken.

		Both perceived and actual benefits and costs may push patients toward a specific setting for low-acuity medical conditions.

		Modifying the system to create net-positive value for each stakeholder group could increase the likelihood of sustainable change.

Healthcare expenditures in the United States reached $2.6 trillion in 2010, nearly 18% of gross domestic product (GDP).

 Rising costs have led to discussion about value—how invested time, money, and resources improve health. An Institute of Medicine roundtable advocated rewarding “value over volume,” compensating effective care, not “more care.”

 The Affordable Care Act (ACA) also supports the concept through value-based purchasing, accountable care organizations, and bundled-payment programs.

The role and measurement of value in healthcare is just emerging.

 There has been little focus on measuring value in emergency departments (EDs), where 28% of acute care in the United States occurs.8 One subset of ED visits for which value is questioned is low-acuity encounters, often perceived by media, insurers, researchers, and emergency physicians as inefficient resource use.

These visits are controversial for several reasons. Terms like 

unnecessary, avoidable, preventable, ambulatory-case sensitive, inappropriate, non-urgent

lack precise definitions and are used interchangeably despite subtle differences. They may refer to encounters for conditions that are not life-threatening, not time-sensitive, capable of improving without intervention, or better suited for different settings. They may suggest visits preventable through better primary care or public health measures or those for alternative purposes like seeking food, shelter, or narcotic medication.

Assessing urgency is also itself controversial. Urgency is complicated 

 by its subjective and dynamic nature. A prudent layperson patient may perceive symptoms as urgent that a doctor does not.

Highly trained providers make inconsistent assessments of urgency at triage,

 and even emergency physicians sometimes alter their initial assessments of urgency after ancillary testing data.

 Urgency is complicated ex post by retrospective measurement. Final diagnoses do not always reflect the potential acuity of presenting complaints.

The estimated range of low-acuity visits (8%-50%) is wide, underscoring the difficulty in quantifying this problem.

The cost associated is unknown, though comparing these figures with total US emergency care expenditures of $51 billion suggests a span of $4 to $26 billion.

 In addition to variability in measuring the impact of low-acuity visits, discussion of this topic often fails to account for perspective—while payers prefer to limit expensive care, patients may desire immediacy or

This paper aims to better the understanding of service setting and value for low-acuity encounters by adapting an existing business model to highlight qualitative and quantitative factors that affect key stakeholder perspectives (patients, insurers, and society). Finally, we discuss how aligning value among groups could guide stakeholders to influence each other and create rational change in the delivery of care.

In business, it is axiomatic that success requires producing value for customers. Although economics in medicine are distorted by the amorphous nature of health, the disconnect between patient expenses and those of third-party payers, and a lack of transparency, the goal of creating value remains unchanged. The Customer Value Equation by Heskett et al models customer perspective and is used to explain the success of companies in industries from airlines to auto insurers

In Heskett’s equation, results are the quantity and quality of products. Process quality is customer experience: 

 (staff knowledge and ability to inspire trust), and 

 Price is what the customer pays for the product. And, access cost denotes what the customer must do to acquire it (travel time).

We adapt this equation to low-acuity encounters to understand how setting and perspective 

 of care (benefits) and the denominators 

(costs), highlighting the concept that, regardless of perspective, value varies directly with costs and benefits (

). To simplify discussion, we assume patients desiring care will receive it somewhere and not avoid care entirely.

Conscious and unconscious value assessments guide patients in choosing care setting. 

 summarizes variables that impact the Patient Value Equation (PVE). To understand how setting influences these variables, one must consider the characteristics and available resources of each (

Output: Outcomes as perceived by patient. 

Patient perceptions dictate the outcome of the PVE. Some patients are less concerned with traditional quality indicators than the impact on their physical and emotional well-being. For example, a patient with a urinary tract infection may be unaware whether she received the recommended antibiotic; however, she is undoubtedly conscious of whether and how quickly her symptoms subsided.

Patients often equate “more” care with better care.

A patient with an upper respiratory infection may prefer knowing that a chest x-ray is normal to having a clinical diagnosis alone. The result is that immediate capabilities, medications, and onsite consulting specialists in EDs may enhance their appeal.

Patients likewise value the experience associated with obtaining care—distance to care, facility quality, and staff courtesy. Patients cite non-clinical factors as playing a larger role than clinical reputation in guiding care site selection.

 A need for after-hours care or safety net, difficulty obtaining traditional appointments, and a desire for immediate care drive patients to the ED.

Over time, patients may also develop loyalty to a particular care site based on positive prior experiences.

Survey data on factors that make patients choose retail and urgent care is lacking. Expanded service hours, same-day access, convenient locations, and minimal wait times could play a role. Yet some patients still prefer EDs to alternative settings. One survey concluded that patients were willing to pay an additional $31 to see physicians in a non-retail setting compared with nurse practitioners in a retail setting.

 Shortages or outright absence of retail and urgent care settings in medically underserved areas may also restrict alternatives to the ED.

By comparison, office-based practices offer a longitudinal, established relationship with providers. Difficult same-day access may outweigh this benefit. Patients report a willingness to pay an additional $82 to be seen the same day rather than to wait 1 or more days.

This perspective is understandable considering that patients in significant pain may prefer early evaluation over a familiar provider.

The denominator of the PVE includes inputs of care, or costs. Patients are often responsible for only a portion of direct expenses such as deductibles, copayments/coinsurance, and a percentage of charges, depending on insurance status. Premiums likely have less impact on patient value because they are sunk costs already paid and unchanged regardless of utilization.

Some data suggest patient finances have minimal impact on seeking care. In a survey of ED patients, few rated ability to pay as an influence on setting selection despite perception that alternative care sites are cheaper.

Lack of insurance may not drive ED utilization, as visits have risen most among the insured.

 ED visit out-of-pocket payments may be minimal for certain insured patients whose insurers pay the bulk of the cost and for certain uninsured patients whose EDs do not collect payment during the visit or pursue collections aggressively. Although several studies show reduction in ED utilization at higher copayments, the effect has been inconsistent.

Few comparative data are available on the impact of patient costs in alternative settings. Uninsured or underinsured plans may limit access to office-based practices. Insurance coverage for retail visits is limited but expanding.

 However, retail clinic users are less likely to be poor and may be able to afford care regardless of coverage.

 Also, transparent pricing at retail clinics may be alluring, as patients can predict their out-of-pocket payment.

Indirect costs of seeking care are an important element of care-setting selection. These opportunity costs include hourly or self-employed workers who lose income receiving treatment during work hours or families who incur child care expenses for similar waits. Treatment in office-based settings may require visits to multiple venues (reference laboratory, outpatient radiology facility, etc) to complete a work-up compared with a single ED visit. Although opportunity costs remain difficult to quantify, they play a role in patient value and should not be ignored.

By comparing patients’ perceptions of benefit and costs of care, the PVE provides a framework to discuss how patients obtain care. It demonstrates that components are dynamic and vary by illness, community, patient personality, and beliefs.

Despite similarities to the patient equation, the Insurer Value Equation (IVE) reflects several key differences.

Output: Effect on future healthcare use. 

The numerator still reflects outcomes of care but gauges results by whether they prevent future healthcare consumption and fulfill contractual obligations more than their effect on patients’ physical and emotional states.

Few quality metrics exist for low-acuity conditions; however, 1 study compared ED, urgent care, retail, and outpatient clinic quality and showed similar overall results among the settings, with ED outcomes being slightly poorer than others.

Little is understood about how low-acuity visits impact future consumption. An upper respiratory infection will likely self-resolve such that receiving care may have little effect on future health. This visit may present scant benefit to the insurer.

Insurer type may also impact benefit. Private insurers and Medicaid presumably see limited enrollment duration and younger populations than Medicare. Treatments and preventive strategies with delayed effects are less likely to affect future healthcare consumption while still enrolled in the former plans. This suggests that private insurers and Medicaid are disproportionately affected by short-term future healthcare consumption while Medicare may inherit long-term consumption.

To analyze value of low-acuity care, an existing model is adapted to highlight factors impacting how stakeholders assess emergency department care compared with alternatives.

Lori Uscher-Pines, PhD, MSc

Articles

Emergency Department Visits for Nonurgent Conditions: Systematic Literature Review

Measuring Value for Low-Acuity Care Across Settings