Just 3.3% of ED Visits Are Truly "Avoidable," Study Finds

Most emergency department (ED) visits may not be as preventable as once thought. A new study in the International Journal for Quality in Health Care pointed out that while some estimates of “avoidable” ED visits have run anywhere between 4.8% and 90%, the reality is even lower.

An analysis of data from the National Hospital Ambulatory Medical Care Survey for the years 2005 to 2011 conservatively defined avoidable ED visits as those where patients did not require any diagnostic or screening services, procedures, or medications, and were discharged home. By that definition, avoidable ED visits only accounted for 3.3% of all ED visits. The authors used such a conservative definition to determine the proportion of truly avoidable ED visits for which policy interventions would present less harm.

"We found that many of the common conditions of 'avoidable' emergency department visits involved mental health and dental problems, which ERs are generally ill-equipped to treat," lead study author Renee Hsia, MD, MSc, of the Department of Emergency Medicine at the University of California, San Francisco, said in a statement. "This suggests a lack of access to healthcare rather than intentional inappropriate use is driving many of these 'avoidable' visits. These patients come to the ER because they need help and literally have no place else to go."

Of patients with avoidable ED visits, 70% were white and 25% were black, and 33% were privately insured, 28% were uninsured, 22% were insured through Medicaid, and 8% were insured through Medicare. Only 14% of avoidable visits arrived by ambulance.

The top 3 diagnoses of these visits to the ED were alcohol abuse, dental disorders, and depressive disorders. Examining the diagnoses found that alcohol-related and mood disorders accounted for 6.8%, while dental disorders accounted for 3.9%. Overall, 10.4% of visits by patients with alcohol-related disorders, 16.9% of mood disorders such as depression and anxiety, and 4.9% of dental conditions were considered avoidable.

“Emergency physicians are trained to treat life- and limb-threatening emergencies, making it inefficient for patients with mental health, substance abuse, or dental disorders to be treated in this setting,” the authors wrote. “One potential mechanism to more appropriately direct limited healthcare resources could be to increase access to mental health and dental care, which have traditionally been treated as separate categories of healthcare.”

The authors pointed out that only 46 states offer dental coverage for non-pregnant adult Medicaid enrollees, and of those only 28 provide coverage for preventive services with the other 18 only covering emergency services.

The American College of Emergency Physicians (ACEP) pointed to the findings of the study as proof that most ED visits are not avoidable and that the ED is not being misused.

"Despite a relentless campaign by the insurance industry to mislead policymakers and the public into believing that many ER visits are avoidable, the facts say otherwise," said Becky Parker, MD, FACEP, president of ACEP. "Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about 'unnecessary' ER visits are just that—myths."