Recent analyses of interventions for avoidable emergency department visits

Over the past several years there has been substantial interest in reducing avoidable emergency department (ED) visits. A wide variety of strategies have been employed to achieve these reductions, including:

  • Benefit design changes such as increasing visit copays or putting limits on the reimbursement of number of unnecessary ED visits by a single patient
  • Provider incentives through programs such as patient-centered medical homes (PCMHs) to reduce the avoidable ED rate
  • Structural delivery system changes to emphasize urgent care facilities and after-hours primary care

Many of these interventions rely on analytics based on the avoidable ED algorithm from New York University (NYU), which uses a probabilistic algorithm based on primary diagnosis code to identify the likelihood of avoidable ED visits within populations. Several analyses have now been done that analyze the effectiveness and/or the safety of these interventions.

The first analysis was done by the Washington state Health Care Authority (HCA). It cites an over 10% decrease in ED utilization and ED per member per month (PMPM) costs in the first six months of a program instituting seven best practices for Medicaid enrollees in the state. The best practices included the electronic exchange of information between emergency departments, patient education of ED utilizers, sharing of lists of frequent ED utilizers, development of ED care plans, guidelines and monitoring of narcotic prescribing, and the periodic review of feedback reports. For more information on this program, read HCA’s report, Emergency Department Utilization: Assumed Savings from Best Practices Implementation.

The second is a peer-reviewed study by ED physicians, whose conclusion is that the NYU ED algorithm does a relatively poor job in identifying an individual patient’s need for an ED visit. In this study they compared presenting complaint data with ED discharge diagnosis run through the NYU ED algorithm. They found that the presenting complaint predicted poorly whether the visit should have been avoided and that doing so could have safety consequences. While arguably the NYU ED algorithm wasn’t designed to guide individual patient decisions, the article is thought-provoking and undoubtedly can be cited as an argument against ED visit interventions. Read this recent article in the Journal of the American Medical Association (JAMA), “Comparison of Presenting Compaint vs. Discharge Diagnosis for Identifying ‘Nonemergency’ Emergency Department Visits,” for more information.

I’d expect many more articles to be published about these interventions in the coming months and years. It will be important for informatics to be aware of these evaluations.

This article first appeared at Milliman MedInsight.