To ED or not to ED, that is the question: Avoidable Emergency Department Use in Massachusetts

The use of emergency departments (EDs) for non-urgent medical conditions is a growing policy focus in the United States and in Massachusetts. Many policymakers believe that it is essential to shift ED use for non-urgent health problems to community settings to relieve crowded EDs, lower the cost of care, and improve quality. Analyses of avoidable ED visits focus on two types of visit categories: visits that could have been treated by a primary care provider (e.g. a visit for an ear infection) and visits that did not require any immediate medical care (e.g. a visit for a bad sore throat with no fever).[1]

In the 2016 Cost Trends Report, the Health Policy Commission (HPC) reported that 42% of all ED visits in Massachusetts in 2015 were avoidable, a share that has remained constant since 2011. HPC expanded this analysis to better understand these avoidable ED visits. 

As seen in the map below, HPC also found that the share of all ED visits that was considered avoidable was fairly consistent throughout the Commonwealth in 2015. In other words, avoidable ED visits are a state-wide concern. There was some variation, however, in the most common condition by zip code. In 2015, the most common conditions for which people had an avoidable ED visit were [2]:

  1. Sinusitis
  2. Stomach pain
  3. Rashes and skin conditions
  4. Acid reflux
  5. Bronchitis
  6. Dental pain
  7. Back pain
  8. Allergies
  9. Urinary tract infections
  10. Ear and eye infections

Source: HPC analysis of Center for Health Information and Analysis Emergency Department Database, 2015

The use of EDs to treat conditions that are non-emergent or amenable to primary care can be an indicator of barriers to accessing primary care. Many studies have shown that when individuals are unable to visit or speak with providers, they are more likely to use the ED.

Source: HPC analysis of Center for Health Information and Analysis Emergency Department Database, 2015

As seen in the graph, the HPC found that a majority of avoidable ED visits in 2015 (69.2%) took place between the hours of 8am and 8pm. While limited access to care outside of normal daytime hours also represents a problem, the fact that most avoidable ED visits occur during daytime hours suggests deeper problems of access to care. Among respondents of the 2014 Massachusetts Health Insurance Survey who had been to the ED in the past year, over half said they had done so because they could not get a timely appointment with their usual source of care. Some potential solutions that could improve access to timely primary care include connecting patients with retail clinics and urgent care centers, expanding provider office hours and the availability of nurse hotlines and telehealth, and granting Nurse Practitioners full practice authority.

 

[1] The HPC used the Billings algorithm to categorize ED visits. The Billings algorithm uses the patient’s primary diagnosis to categorize a visit into broad categories: emergent, non-emergent (a patient’s initial complaint, presenting symptoms, vital signs, medical history and age indicated that immediate medical care was not required in 12 hours), and emergent, primary care treatable (treatment was required within 12 hours, but care could have been provided effectively and safely in a primary care setting). Behavioral health-related visits and injuries are identified by the algorithm, but are not classified into any of these category types. HPC considered non-emergent and emergent, primary care treatable visits “avoidable”.

[2] Any discharge that the Billings algorithm classified as being at least 75% non-emergent or emergent, primary care treatable was used for this analysis.