Who uses emergency departments inappropriately and when - a national cross-sectional study using a monitoring data system

Abstract

BackgroundIncreasing pressures on emergency departments (ED) are straining services and creating inefficiencies in service delivery worldwide. A potentially avoidable pressure is inappropriate attendances (IA); typically low urgency, self-referred patients better managed by other services. This study examines demographics and temporal trends associated with IA to help inform measures to address them.MethodsUsing a national ED dataset, a cross-sectional examination of ED attendances in England from April 2011 to March 2012 (n = 15,056,095) was conducted. IA were defined as patients who were self-referred; were not attending a follow-up; received no investigation and either no treatment or ‘guidance/advice only’; and were discharged with either no follow-up or follow-up with primary care. Small, nationally representative areas were used to assign each attendance to a residential measure of deprivation. Multivariate analysis was used to predict relationships between IA, demographics (age, gender, deprivation) and temporal factors (day, month, hour, bank holiday, Christmas period).ResultsOverall, 11.7% of attendances were categorized as inappropriate. IA peaked in early childhood (adjusted odds ratio (AOR) = 1.53 for both one and two year olds), and was elevated throughout late-teens and young adulthood, with odds reducing steadily from age 27 (reference category, age 40). Both IA and appropriate attendances (AA) were most frequent in the most deprived populations. However, relative to AA, those living in the least deprived areas had the highest odds of IA (AOR = 0.89 in most deprived quintile). Odds of IA were also higher for males (AOR = 0.95 in females). Both AA and IA were highest on Mondays, whilst weekends, bank holidays and the period between 8 am and 4 pm saw more IA relative to AA.ConclusionsPrevention of IA would be best targeted at parents of young children and at older youths/young adults, and during weekends and bank holidays. Service provision focusing on access to primary care and EDs serving the most deprived communities would have the most benefit. Improvements in coverage and data quality of the national ED dataset, and the addition of an appropriateness field, would make this dataset an effective monitoring tool to evaluate interventions addressing this issue.

Factors Contributing to Inappropriate Visits of Frequent Attenders and Their Economic Effects at an Emergency Department in Singapore

“…The literature on this topic is extensive, but no researcher has been able to define it in an obviously valid way. 40,41 Some authors have defined inappropriate as being problems that could be adequately treated in primary care settings, 42,43 but this is useless from a patient standpoint because it must be made retrospectively. Using triage criteria may be equally flawed as some "minor" problems should be treated relatively urgently.…”

Primary Care Access, Emergency Department Visits, and Unplanned Short Hospitalizations in the UK

“…Up to 40% of ED visits are believed to be "inappropriate" and potentially treatable in primary care, 8 most commonly among very young children. 9 Two-thirds of all unplanned hospitalizations in children are for a short stay (<2 days) for mostly minor conditions, which, it has been argued, may be more appropriately managed in the community. 10 Certainly, short hospitalizations for chronic conditions have been positively associated with withdrawal of primary care.…”

Emergency Care Services

“…"Inappropriate" or non-urgent visits are characterised by low urgency problems and require other health services than emergency admission including, for example, telephone-based services and primary or community health care services (McHale et al, 2013). Such inappropriate ED visits are for conditions that could be better managed in the community by a general practitioner (GP) or by the broader primary care clinical team.…”

“…Lastly, the opportunity cost associated with inappropriate ED visits might also be significant. In England for example, the cost of inappropriate visits was estimated at nearly £100 million between (McHale et al, 2013.…”

“…In England, different estimates suggest that the proportion of inappropriate ED visits ranges from 11.7% (McHale et al, 2013) to 15% (Wise, 2014).…”