Comparison of Presenting Complaint vs Discharge Diagnosis for Identifying “ Nonemergency” Emergency Department Visits

• Published in: JAMA : the journal of the American Medical Association 2013-03, Vol.309 (11), p.1145-1153
• Main Authors: Raven, Maria C, Lowe, Robert A, Maselli, Judith, Hsia, Renee Y
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Aged; Aged, 80 and over; Algorithms; Biological and medical sciences; Comparative studies; Cost reduction; Data Collection; Diagnosis; Discharge; Eligibility Determination; Emergency medical care; Emergency Medical Services - standards; Emergency Service, Hospital - statistics & numerical data; Female; General aspects; Health care expenditures; Health Care Surveys; Humans; Insurance Coverage; International Classification of Diseases; Male; Medical sciences; Middle Aged; Patient Admission - statistics & numerical data; Patient Discharge - statistics & numerical data; Primary Health Care; Severity of Illness Index; United States; Young Adult
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2013.1948

IMPORTANCE Reduction in emergency department (ED) use is frequently viewed as a potential source for cost savings. One consideration has been to deny payment if the patient's diagnosis upon ED discharge appears to reflect a “nonemergency” condition. This approach does not incorporate other clinical factors such as chief complaint that may inform necessity for ED care. OBJECTIVE To determine whether ED presenting complaint and ED discharge diagnosis correspond sufficiently to support use of discharge diagnosis as the basis for policies discouraging ED use. DESIGN, SETTING, AND PARTICIPANTS The New York University emergency department algorithm has been commonly used to identify nonemergency ED visits. We applied the algorithm to publicly available ED visit data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) for the purpose of identifying all “primary care–treatable” visits. The 2009 NHAMCS data set contains 34 942 records, each representing a unique ED visit. For each visit with a discharge diagnosis classified as primary care treatable, we identified the chief complaint. To determine whether these chief complaints correspond to nonemergency ED visits, we then examined all ED visits with this same group of chief complaints to ascertain the ED course, final disposition, and discharge diagnoses. MAIN OUTCOMES AND MEASURES Patient demographics, clinical characteristics, and disposition associated with chief complaints related to nonemergency ED visits. RESULTS Although only 6.3% (95% CI, 5.8%-6.7%) of visits were determined to have primary care–treatable diagnoses based on discharge diagnosis and our modification of the algorithm, the chief complaints reported for these ED visits with primary care–treatable ED discharge diagnoses were the same chief complaints reported for 88.7% (95% CI, 88.1%-89.4%) of all ED visits. Of these visits, 11.1% (95% CI, 9.3%-13.0%) were identified at ED triage as needing immediate or emergency care; 12.5% (95% CI, 11.8%-14.3%) required hospital admission; and 3.4% (95% CI, 2.5%-4.3%) of admitted patients went directly from the ED to the operating room. CONCLUSIONS AND RELEVANCE Among ED visits with the same presenting complaint as those ultimately given a primary care–treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discha