Discharge diagnoses in the E.R. cannot retrospectively identify non-emergent visits

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1. A significant number of emergency department visits with primary care-treatable diagnoses require immediate intervention or admission.  

2. Discharge diagnoses cannot accurately identify non-emergency ED visits.

Being a key gateway to the healthcare system, emergency department utilization is often assumed to be a convenient target for policy interventions to promote savings. The results of this study suggest that payment denial decisions based solely on “nonurgent” ED chief complaints or discharge diagnoses would be unwarranted as the study did not find a strong association between incoming chief complaint and discharge diagnosis.As a study limitation, focusing on the chief complaint or discharge diagnosis is limiting because these are often the least sophisticated part of the evaluation. With poor concordance between ED discharge diagnosis and chief complaint, the study reinforces the notion that payment solutions should not be based on oversimplified conclusions and assumptions about a patient’s disposition.

Rather, decisions should ideally be intimately tied to patient information sharing about the patient’s overall condition. It’s the complex patients and those with chronic disease that appear to be better targets for improved cost reduction. Often these patients come to the ED having been to multiple other hospitals, so the ED lacks accurate history and disease course information. Until health information can be shared across hospital systems more readily, emergency departments should be obtaining outside records as part of the early evaluation process of complex patients, so as to better coordinate care and reduce wasteful or harmful diagnostic steps. The decision support systems and mobile technology that will become standard practice in coming years will better triage patients, but for now, better managing the complex patients that do come to the ED will offer significant cost savings. Future emergency medicine health services research should determine how to best predict non-emergent cases.

Click to read the study, published today in JAMA

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1. A significant number of emergency department visits with primary care-treatable diagnoses require immediate intervention or admission.

2. Discharge diagnoses cannot accurately identify non-emergency ED visits.

This [retrospective] study: The study used the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) data focused on 34,942 emergency department (ED) visits excluding those resulting in admission. The New York University ED algorithm was used to identify visits as either emergent (needing care within 12 hours) or non-emergent. Those classified as emergent were further split into those needing an ED or those able to be treated emergently by primary care. 6.3% had primary-care treatable diagnoses based on discharge diagnosis, but the associated presenting complaints were the same for 88.7% of all ED visits. The primary care-treatable group was only classified as such if the algorithm predicted a 100% probability that the diagnosis was primary care treatable. Chief complaints were catalogued in a standard NCHS fashion. Of the chief complaints that were identical to those generated by the visits with primary-care treatable diagnoses, 11.1% had been triaged to needing immediate or emergent care.

Further reading:

1. Matthews AW Medicaid cuts rile doctors: hospitals also fight Washington state’s drive to trim emergency room vistis.
   
2. A matter of urgency: reducing emergency department overuse 

In sum: Being a key gateway to the healthcare system, emergency department utilization is often assumed to be a convenient target for policy interventions to promote savings. The results of this study suggest that payment denial decisions based solely on “nonurgent” ED chief complaints or discharge diagnoses would be unwarranted as the study did not find a strong association between incoming chief complaint and discharge diagnosis.As a study limitation, focusing on the chief complaint or discharge diagnosis is limiting because these are often the least sophisticated part of the evaluation. With poor concordance between ED discharge diagnosis and chief complaint, the study reinforces the notion that payment solutions should not be based on oversimplified conclusions and assumptions about a patient’s disposition.

Rather, decisions should ideally be intimately tied to patient information sharing about the patient’s overall condition. It’s the complex patients and those with chronic disease that appear to be better targets for improved cost reduction. Often these patients come to the ED having been to multiple other hospitals, so the ED lacks accurate history and disease course information. Until health information can be shared across hospital systems more readily, emergency departments should be obtaining outside records as part of the early evaluation process of complex patients, so as to better coordinate care and reduce wasteful or harmful diagnostic steps. The decision support systems and mobile technology that will become standard practice in coming years will better triage patients, but for now, better managing the complex patients that do come to the ED will offer significant cost savings. Future emergency medicine health services research should determine how to best predict non-emergent cases.

Click to read the study, published today in JAMA

By Mike Hoaglin and Rif Rahman

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