Is 3.3% Really the Avoidable Number?

Much has been made about “avoidable” Emergency Department visits – something, as physicians, we are anecdotally all-too-familiar – but the exact scope of the problem has been difficult to quantify. If it were easy, after all, the range of estimates for avoidable visits would not encompass the spread between 4.8% and 90%.

This is another shot at defining avoidable, this time using a very restrictive definition. An avoidable ED visit occurs when a patient is discharged home, and:

  • No tests are performed
  • No procedures are performed
  • No medications are administered or prescribed

These authors utilize the National Hospital Ambulatory Medical Care Survey (NHAMCS) for years 2005–2011, and find an estimated 3.3% of ED visits met those criteria. The most common discharge diagnoses included those related to alcohol use, back pain, throat pain, upper respiratory symptoms, dental issues, and mental health issues.

But, the true net result of this analysis is, unfortunately, it simply grows our estimate for avoidable ED visits to an even-more-ridiculous range between 3.3% and 90%. This definition lends itself far more to convenience for data analysis than face validity as a surrogate for avoidable. Clearly, a lack of testing or medication administration does not indicate a life- or limb-threatening condition has not been ruled out by expert clinical examination and reasoning. Conversely, ordering a test or administering a medication does not indicate the level of service of an ED was necessary, or the ideal venue for care delivery.

Given the limitations of the data set, this is a reasonable approach to add to the discussion of the types of potentially avoidable ED visits. However, I expect to see this 3.3% number cited frequently in isolation without acknowledging the underlying definitions or methods for derivation.  A better title for this paper?  How about: “ED visits resulting in neither treatment nor testing: a descriptive analysis” – the word “avoidable” should be omitted.

“Avoidable emergency department visits: a starting point”