Identifying Characteristics of Patients With Low Urgency Emergency Department Visits In a Managed Care Setting

MANAGED CARE October 2010. ©MediMedia USA

A straightforward method of identifying potentially non-urgent ED visits from administrative data can be employed to calculate population-based rates, which might be applied in the development of managed care programs

James W. Davis, PhD

Hawaii Medical Service Association (an independent licensee of the Blue Cross and Blue Shield Association) and the John A. Burns School of Medicine at the University of Hawaii

Ronald Y. Fujimoto, DO

Hawaii Medical Service Association

Henry Chan, BS

Hawaii Medical Service Association

Deborah T. Juarez, Sc.D

Hawaii Medical Service Association and the John A. Burns School of Medicine Department of Public Health Sciences at the University of Hawaii

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Abstract

Purpose: Studies worldwide in emergency departments (ED) find that a substantial proportion of patients seek care for non-urgent conditions.

Managed care programs may help address this overuse of ED facilities, but non-urgent ED care is not easily identified outside of ED settings. This article employed an algorithm using insurance data to identify and characterize patients having low urgency ED visits. Non-urgent is the term used in the ED literature for ED visits that might have been managed outside an ED setting such as in a physician office. Low urgency ED visits could include visits that require an ED setting but for less severe conditions than high urgency ED visits.

Design: Analysis of ED visits by members of the largest health insurer in Hawaii.

Methodology: Visits were defined as low urgency if classified by the ED as low severity and if, in addition, the patients required no procedures beyond physician and nursing care. A simple example would be a physician order for a laboratory test. Even if the test was routine, the fact the doctor ordered the test during the ED visit suggests the result might be needed right away to make a management decision. Another example of a procedure would be a radiograph.

Principal finding: Medicaid participants, children age 1 to 5, and people living on less populated Hawaiian Islands most frequently had low urgency visits. The visits were also more common on weekends than weekdays, and more common among males compared to females. Of all low urgency visits by Medicaid participants, 32% were by repeat users of the ED.

The percentage for members of non-Medicaid plans was 16%. People with one low urgency visit in the past year were more than twice as likely as others to have a similar visit in the next year. People with two or more low urgency visits in the past year were five times as likely to have a low urgency ED visit in the next year.

Conclusion: The results identify several areas such as youth, island of residence, and past history of low urgency ED visits that might become the focus of managed care programs.