On "unnecessary" ED visits: background reading

Here are a bunch of very informative pieces on why trying to blame excessive costs or busy-ness on low acuity patients in the ED is, at best, a misguided effort:

1) Great overview of many systemic issues which funnel patients to emergency departments, by Annals of Emergency Medicine Editor in Chief Mike Callaham*:
The Prudent Layperson’s Complicated and Uncertain Road to Urgent Care

2) We can't discern low acuity diagnoses from chief complaints, by Maria Raven, Robert Lowe, Judith Maselli, and Renee Hsia in JAMA:
Comparison of Presenting Complaint vs Discharge Diagnosis for Identifying “ Nonemergency” Emergency Department Visits and accompanying editorial by my (now) chair:
some intuitive, oversimplified, yet enduring beliefs about nonurgent patients in the ED should be abandoned. Trying to discern low-acuity conditions and putting up barriers to receiving care or denying payment after receiving care will work no better in future generations than in the past. Attention should be redirected away from penalizing patients, physicians, or hospitals when a condition turns out to be minor. Instead, the emphasis should be on integration across sites of care, especially for the most complex and most expensive patients.
and from his response to a Letter:
The reasons people visit the ED for care are often rational and understandable, driven by a perceived need for immediacy of treatment and lack of an accessible alternative. Many conditions treatable in primary care that are cared for inside EDs in the United States may reflect problems with alternative access to rather than inappropriate actions by the patient.
3) Low acuity ED visits is just not where the money is, by Peter Smulowitz, Leah Honigman and Bruce Landon, in Annals of EM:
A novel approach to identifying targets for cost reduction in the emergency department.

4) EDs aren't overcrowded because of low acuity patients; we are busy because of boarding -- patients we have seen & admitted in the ED and are waiting for their inpatient beds. (tons on this, here's one on how boarding-> crowding in Annals by Brent Asplin et al A conceptual model of emergency department crowding, and 2 of my blog posts 4A) here and 4B) here and 14 below)

5) And for those who suggest higher patient copays for low acuity ED visits, the famous RAND HIE, which shows that patients who have to spend more out of pocket decrease *all* care, both appropriate & inappropriate care (which isn't surprising, given Raven's study, above):

Here are a few studies that show that retail clinics tend to *increase* rather than decrease overall utilization (suggesting something like supply induced demand) and fail to lower (and probably increase!) ED use:
6) Why Retail Clinics Do Not Substitute for Emergency Department Visits and What This Means for Value-Based Care by Jesse Pines in Annals
7) Retail Clinic Visits For Low-Acuity Conditions Increase Utilization And Spending by J Scott Ashwood, Martin Gaynor, Claude Setodji, Rachel Reid, Ellerie Weber, and Ateev Mehrotra in Health Affairs. From what I hear from people who run EDs which opened urgent cares etc, the same holds true, but I don't have great data on that.

UPDATE 12/5/2017
8) Surprise! Uninsured people don't use the ED any more than those with insurance; rather, they use it the same. But, they use other health care less. By Ruohua Annetta Zhou, Katherine Baicker, Sarah Taubman, and Amy Finkelstein in Health Affairs:
The Uninsured Do Not Use The Emergency Department More—They Use Other Care Less

UPDATE 12/18/2017 & 12/25/2017
9) Another great new paper from Maria Raven and Faye Steiner: 1 in 4 patients in the ED were referred from an outpatient provider (and they're more likely to be admitted than other ED patients):
A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization

10) and while finding (9) I found this great review by Maria Raven et al in Annals showing ED visit reduction programs generally don't work:
The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review

11) another British review showing putting "unscheduled care centres (UCC)" in the ED doesn't solve much, by Shammi Ramlakhan, Suzanne Mason, Colin O'Keeffe, Alicia Ramtahal, Suzanne Ablard in EMJ
Primary care services located with EDs: a review of effectiveness

12) This great episode of EM Over Easy on fundamental attribution error
13) David Foster Wallace's This Is Water.
The basic idea: when I cut someone off in traffic, I make excuses for myself (I'm late to work, the light is changing, etc etc) but when someone cuts me off, of course I think they're just a jerk. The less I judge patients for being in the ED, the less stress I have.

14) And here are my 2 blog posts on crowding:
A Spoon in the Bucket?
Empty the Dishwasher

UPDATE 1/29/2018
See my twitter thread on the prudent layperson standard [now here in blog form and here in EP Monthly] which was in response to this article by Sarah Kliff in Vox

15) friendly reminder that the legal definition of a medical emergency is
"a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in... placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; ...serious impairment to bodily functions; ...[or] serious dysfunction of any bodily organ or part.)"

If a regular person with no medical training thinks their symptoms are an emergency, it's an emergency and the insurer has to cover it.

16) it's legislated federal law in the ACA (text)

17) and here is the regulatory version (text)

(for both of these, ctrl+F prudent layperson) to find it

summarized by me here in EP Monthly

18) and before it was federal law for private insurers, it was state law in 32 states + DC (pdf from ACEP)

UPDATE 9/4/2018
19) interesting paper from Sabrina Poon, Jeremiah Schuur, and Ateev Mehrotra analyzing Aetna data:
changes in "low acuity visit" from 2008-2015:
-overall increased by 31% (from 143 to 188 visits per 1,000 members)
-non-ED increased by 140% (from 54 to 131 visits per 1,000 members)
-urgent care increased by 119% (from 47 to 103 visits per 1,000 members)
-retail clinic increased by 214% (from 7 to 22 visits per 1,000 members)
-low acuity ED visits decreased by 36% (from 89 to 57 visits per 1,000 members)
-average overall spending per member increased by 14% (from $70 to $80 per member per year)

[important limitations: single, commercial plan; tough to define what a low acuity visit is (seems to me like their definition gives a useful operational sample, but doesn't define the whole universe of low acuity visits?; and, hindsight bias; and, doesn't look at office-based care; acute unscheduled office care is hard to analyze, etc.]

I have lots of initial thoughts here; mainly, this looks like it didn't save money, we don't know about outcomes, and I think overall this is more about supply-induced demand [funny how non-ED low acuity patients had higher incomes] than meeting unmet demand. But, I also know my priors.

UPDATE 11/26/2018
20) Andy Chou, Suhas Gondi, Olesya Baker, Arjun Venkatesh, and Jeremiah Schuur published a paper in JAMA Network Open** looking at what fraction of patients who could potentially get denied by Anthem's low-acuity ED visit denial policy (see my summary) share symptoms with all ED visitors. No surprises: 15% of patients have diagnoses that might be denied by Anthem; they share symptoms with 87.9% of ED patients.

And a nice accompanying editorial by Maria Raven.

UPDATE 9/23/2020
21) More from Andy ChouSuhas Gondi, Scott WeinerJeremiah Schuur, Benjamin Sommers:
Medicaid expansion associated with only small decreases in ED use among low-income adults--those who reported barriers to care. This is not surprising, as the majority (74%) of low-income adults reported using the ED due to perceived severity of illness. Only 12% came to the ED because clinics were closed, and only 9.5% due to barriers to care. This reinforces that people use the ED because they think they are having an emergency (which is the appropriate and legal definition of an emergency):

Medicaid Expansion Reduced Emergency Department Visits by Low-income Adults Due to Barriers to Outpatient Care

UPDATE 12/1/2020
22) Very nice but obviously frustrating thread by Michael Anne Kyle, a health policy PhD student at Harvard who details her experience trying to get her minor foot injury worked up without, but ultimately only being able to go to the ED:

UPDATE 12/4/2020
23) Didn't realize I never added the paper I wrote with Kao-Ping Chua, Aamir Hussein, Aisha (Liferidge) Terry, Steve Pitts, and Jesse Pines
We looked at what happened to patients in EDs (eg labs, imaging, medications, procedures, dispo) and when (evenings, nights, weekends) and compared what visits theoretically could have been substituted at primary care offices, retail clinics, and urgent care centers based on strict vs very generous estimates of alternative sites' capabilities & hours. Note we did not look at insurance, liability or clinical comfort, or actual ability to schedule an appointment so these are pretty generous estimates (on the other hand some things like some labs or x-rays may have happened more generously at EDs that alternate sites would be fine not doing; but I doubt this would change our results much tbh). 
Based on 2011 NHAMCS we found these strict–generous estimates of how many ED patients had services that theoretically could have been done at alternative sites: "Our criteria classified 5.5%–27.1%, 7.6%–20.4%, and 10.6%–46.0% of visits as substitutable in primary care offices, retail clinics, and urgent care centers, respectively."

Just because something could be seen at a (cheaper) site doesn't mean it's not a PLS emergency, eg ankle sprain at 6pm. Could an urgent care have taken care of it? Of course. But if none are open, and it might be broken, etc…

UPDATE 4/13/2021
24) Are urgent care visits near an ED associated with lower ED visits? Is adding an urgent care near an ED associated with lower ED visits? Bill Wang, Ateev Mehrotra, and Ari Friedman look at some lower acuity diagnoses visits at EDs & UCCs by ZIP code; they also looked at when a ZIP crossed from <90th percentile in UCC visits to >90th percentile, suggesting a high-volume UCC was opened in a ZIP.

No surprises:
-an increase of 37 lower-acuity urgent care center visits per enrollee was associated with a decrease of a single lower-acuity ED visit per enrollee (54 when excluding the 3 states with the most FSEDs)
-each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs

Obviously not each of these 37 visits would have otherwise been an ED visit; some would have been primary care; many more would not have happened at all (pent-up demand vs supply-induced demand). Regardless, access to UCCs is not magically "fixing" low-acuity ED visits.

UPDATE 12/30/2021
25) Fantastic overview & update of crowding by a number of academic emergency medicine chairs in NEJM catalyst, just absolutely fantastic:

Gabor D. Kelen, Johns Hopkins University
Richard Wolfe, Beth Israel Deaconess
Angela M. Mills, Columbia
Deborah Diercks, UTSW
Susan A. Stern, University of Washington
Peter E. Sokolove, UCSF

UPDATE 1/30/2023
26) Pall Care doc Erek Majka and I discuss, well, all of this in the context of patients with cancer in JNO:

UPDATE 1/26/2024
27) Theodoros Giannouchos, Benjamin Ukert and Brad Wright did essentially a Raven 2.0 (2 above) again demonstrating very little association between reasons for visit and diagnosis in JAMA Network Open**.

and an accompanying commentary from Jay Schuur:

*COI: I am was Social Media Editor for Annals which makes made Mike my boss.
**COI: I am Digital Media Editor for JAMA Network Open