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The American Journal of Managed Care January 2013
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Emergency Department Visits for Nonurgent Conditions: Systematic Literature Review
Lori Uscher-Pines, PhD, MSc; Jesse Pines, MD, MBA; Arthur Kellermann, MD, MPH; Emily Gillen, MA; and Ateev Mehrotra, MD, MS
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Emergency Department Visits for Nonurgent Conditions: Systematic Literature Review

Lori Uscher-Pines, PhD, MSc; Jesse Pines, MD, MBA; Arthur Kellermann, MD, MPH; Emily Gillen, MA; and Ateev Mehrotra, MD, MS
This article presents a systematic review of the US literature on factors influencing the decision to visit the emergency department for nonurgent conditions.
It is widely presumed that redirecting nonurgent visits to alternate settings is a desirable policy goal, if for no other reasons than to reduce healthcare spending and enable EDs to focus their efforts on more acutely ill and injured patients. However, efforts to deter nonurgent ED use could produce unintended consequences. Imposition of steep copayments and deductibles to discourage ED use might deter some patients from timely care-seeking for serious or even life-threatening problems. Even steering patients to alternate settings from the ED triage desk is not without risk. Some studies have shown that as many as 3% to 5% of patients triaged as nonurgent require immediate hospitalization after further evaluation in the ED.1 Another unintended consequence to consider is increased utilization; efforts to encourage alternatives to the ED (eg, retail clinics) might induce patients who previously would have stayed at home to seek care. Likewise, it is only acceptable to discourage nonurgent use in communities where patients have real alternatives, such as accessible PCPs. High rates of nonurgent ED visits can in fact be an indicator of poor primary care access, as suggested by the ED Use Profiling Algorithm that classifies ED visits by whether they could be treated elsewhere or, although emergent, could have been prevented by earlier access to primary care.53

LIMITATIONS

The major limitation of this review is that the validity of findings is limited by the quality of included articles. Few studied used multivariate statistics, so we are unsure whether the identified factors are associated with nonurgent ED use controlling for other factors. Also, the diverse (and controversial) criteria used to define nonurgent visits limit the comparability of findings. As described above, no 2 studies used the same exact definition of nonurgent visits, identifying nonurgent visits prospectively at triage (eg, based on symptoms) and/or retrospectively (eg, based on ultimate diagnosis). While nonurgent visits seem to represent a significant fraction of all visits, prudent layperson standards that now broadly apply to all health plans require insurers to cover emergency services if a prudent layperson believed he or she was experiencing a medical emergency (regardless of the final diagnosis).54 The standard, advocated by the American College of Emergency Physicians for more than 2 decades, conflicts in principle with the 11 articles that defined urgency based on retrospective review of medical records.

CONCLUSIONS

Despite the significant policy interest in deterring nonurgent ED use, our literature review highlights both the limited understanding of what drives nonurgent ED use and flaws in most of the published studies. If health plans, policy makers, and providers want to reduce use of the ED for nonurgent problems, they must ensure that their interventions are evidence- based and tailored to address the needs and concerns of the populations they are designed to serve.

Author Affiliations: RAND Corporation, Arlington, VA (LU-P, EG), Santa Monica, CA (AK), Pittsburgh, PA (AM); Departments of Emergency Medicine and Health Policy (JP), George Washington University (JP), Washington, DC.

Funding Source: This study was funded by the California Healthcare Foundation.

Author Disclosures: The authors (LU-P, JP, AK, EG, AM) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (LU-P, JP, AM); acquisition of data (LU-P, EG, AM); analysis and interpretation of data (LU-P, JP, AK, EG, AM); drafting of the manuscript (LU-P, AK, AM); critical revision of the manuscript for important intellectual content (LU-P, JP, AK); obtaining funding (LU-P, AM); administrative, technical, or logistic support (EG); and supervision (AM).

Address correspondence to: Lori Uscher-Pines, PhD, MSc, 1200 S Hayes St, Arlington, VA 22202. E-mail: luscherp@rand.org.
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