Background: A large proportion of all emergency department (ED) visits in the United States are for nonurgent conditions. Use of the ED for nonurgent conditions may lead to excessive healthcare spending, unnecessary testing and treatment, and weaker patient-primary care provider relationships. Objectives: To understand the factors influencing an individual's decision to visit an ED for a nonurgent condition. Methods: We conducted a systematic literature review of the US literature. Multiple databases were searched for US studies published after 1990 that assessed factors associated with nonurgent ED use. Based on those results we developed a conceptual framework. Results: A total of 26 articles met inclusion criteria. No 2 articles used the same exact definition of nonurgent visits. Across the relevant articles, the average fraction of all ED visits that were judged to be nonurgent (whether prospectively at triage or retrospectively following ED evaluation) was 37% (range 8%-62%). Articles were heterogeneous with respect to study design, population, comparison group, and nonurgent definition. The limited evidence suggests that younger age, convenience of the ED compared with alternatives, referral to the ED by a physician, and negative perceptions about alternatives such as primary care providers all play a role in driving nonurgent ED use. Conclusions: Our structured overview of the literature and conceptual framework can help to inform future research and the development of evidence-based interventions to reduce nonurgent ED use.
[Show abstract][Hide abstract] ABSTRACT: Background: In the face of escalating spending, measuring and maximizing the value of health services has become an important focus of health reform. Recent initiatives aim to incentivize high-value care through provider and hospital payment reform, but the role of the emergency department (ED) remains poorly defined. Objectives: To achieve an improved understanding of the value of emergency care, we have developed a framework that incorporates the perspectives of stakeholders in the delivery of health services. Methods: A pragmatic review of the literature informed the design of this framework to standardize the definition of value in emergency care and discuss outcomes and costs from different stakeholder perspectives. The viewpoint of patient, provider, payer, health system, and society is each used to assess value for emergency medical conditions. Results: We found that the value attributed to emergency care differs substantially by stakeholder perspective. Potential targets to improve ED value may be aimed at improving outcomes or controlling costs, depending on the acuity of the clinical condition. Conclusion: The value of emergency care varies by perspective, and a better understanding is achieved when specific outcomes and costs can be identified, quantified, and measured. Using this framework can help stakeholders find common ground to prioritize which costs and outcomes to target for research, quality improvement efforts, and future health policy impacting emergency care. (C) 2014 Elsevier Inc.
Journal of Emergency Medicine 05/2014; 47(3). DOI:10.1016/j.jemermed.2014.04.017 · 0.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: ContextEmergency Department (ED) overcrowding due to nonemergent use is an ongoing concern. In 2011, a regional health system that primarily serves rural communities in Texas instituted a new program to medically screen and refer nonemergent patients to nearby affiliated rural health clinics (RHCs).PurposeThis formative evaluation describes the program goals, process, and early implementation experiences at 2 sites that adopted the program before wider implementation within the rural health system.Methods
Primary data collection including document review, internal stakeholder interviews, and direct observation of program processes were used for this formative evaluation of program implementation in light of program goals and objectives. Fourteen key informants were asked questions related to the program concept, structure, and implementation.ResultsThe program, as implemented, aligned with initial program goals, but it was dependent on ED screening staff and RHC availability. Some adjustments to the program were needed, including RHC hours, consistency among staff in making referrals, patient education, and improving patient uptake on the referral. Stakeholders reported lessons learned related to training, staff buy-in, Emergency Medical Treatment and Labor Act (EMTALA), and intraorganizational cooperation.DiscussionThe system was able to leverage excess capacity of affiliated RHCs to accommodate low-acuity patients referred from the ED and may lead to improvements in Triple Aim goals of increased patient satisfaction, better population health and outcomes, and lower per capita costs. Lessons learned from this program may inform similar processes aimed to reduce nonemergency ED utilization by other rural health systems.
The Journal of Rural Health 08/2014; 31(2). DOI:10.1111/jrh.12085 · 1.45 Impact Factor
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