Over the past several years there has been substantial interest in reducing avoidable emergency department (ED) visits. A wide variety of strategies have been employed to achieve these reductions including:

1. Benefit design changes such as increasing visit copays or putting limits on the reimbursement of number of un-necessary ED visits by a single patient.
2. Provider incentives through programs, such as Patient Centered Medical Homes (PCMH) to reduce the avoidable ER rate.
3. Structural delivery system changes to emphasize Urgent Care Facilities and after hours primary care.

Many of these interventions rely on analytics based on NYU’s avoidable ED algorithm which uses a probabilistic algorithm based on primary diagnosis code to identify the likelihood of avoidable ED visits within populations. Several analyses have now been done that analyze the effectiveness and/or the safety of these interventions.

The first analysis was done by the Washington State Health Care Authority (HCA). It cites an over 10% decrease in ED utilization and ED PMPM costs in the first 6 months of a program instituting 7 best practices for Medicaid enrollees in the State. The best practices included the electronic exchange of information between emergency departments, patient education of ED utilizers, sharing of lists of frequent ED utilizers, development of ED care plans, guidelines and monitoring of narcotic prescribing and the periodic review of feedback reports. For more information on this program, read HCA’s report, Emergency Department Utilization: Assumed Savings from Best Practices Implementation.

The second is a peer reviewed study by ED physicians, whose conclusion was that the NYU ED algorithm did a relatively poor job in identifying an individual patient’s need for an ED visit.  In this study they compared presenting complaint data with ED discharge diagnosis run through the NYU ED algorithm. They found that the presenting compliant predicted poorly whether the visit should have been avoided and that doing so could have safety consequences. While arguably the NYU ED algorithm wasn’t designed to guide individual patient decisions, the article is thought provoking and undoubtedly can be cited as an argument against ED Visit interventions. Read recent article in JAMA, Comparison of Presenting Compaint vs Discharge Diagnosis for Identifying “Nonemergency” Emergency Departement Visits for more information. 

I’d expect that many more articles to be published about these interventions in the coming months and years. It will be important for informatics to be aware of these evaluations.