A new study reveals a significant disparity between patients’ reasons for visiting emergency departments and doctors’ evaluations of the urgency of those visits. This misalignment has profound implications for health care policies.
Emergency departments in the United States handle over 140 million visits annually, costing nearly $80 billion. Each interaction is meticulously documented, capturing patients’ reasons for their visits and doctors’ subsequent diagnoses. However, the degree to which doctors and patients agree on the urgency of these visits is surprisingly low.
A recent cross-sectional study conducted by Benjamin Ukert of Texas A&M University School of Public Health, along with colleagues from the University of Alabama at Birmingham and the University of South Carolina, has highlighted a striking disparity. Published in the Journal of the American Medical Association, the research reveals that emergency department doctors and patients concur on the urgency level only about 38% to 57% of the time.
“This is important because nearly 40 percent of emergency department visits are not medical emergencies, which is very costly financially and in terms of staffing and other hospital resources,” Ukert said in a news release. “As a result, state legislatures and health insurers have implemented policies to transfer less-urgent cases to doctors’ offices and urgent care centers, but clinicians face profound challenges in making this decision based on what patients tell them about their condition.”
The study sheds light on the challenges posed by current policies relying on a process known as retrospective review and adjudication. This process uses medical claims and algorithms related to discharge diagnoses to determine if emergency care costs are covered by insurance. However, the findings suggest this system may be flawed.
“Our findings fundamentally challenge this plan design because if patients and doctors provide different evaluations of the urgency of the condition, then incentives to reduce emergency room visits may not be effective,” Ukert added. “For example, if patients could go to a primary care doctor but payment policies rely on reviewing the patient’s diagnosis and treatment after the visit to determine whether the physician assessed the condition correctly, then this would require patients to know that their condition could be treated in a doctor’s office instead of an emergency department.”
Using data from the National Hospital Ambulatory Medical Care Survey, the researchers analyzed 190.7 million emergency department visits among adults aged 18 or older from 2018 to 2019.
Their findings showed a significant discrepancy between patient-reported reasons for visits and the final diagnoses given by doctors. Only 0.4% of visits were classified with 100% confidence based on patient-reported reasons, compared to 38.5% based on discharge diagnoses.
This misalignment underscores the complexity and challenges faced by physicians at the triage level.
“In sum, we found no association between the reasons patients gave for their visit at the time of arrival at an emergency department, their need for emergency department care and their final discharge diagnosis,” added Ukert.
For example, even for severe conditions like strokes or heart attacks, the initial reasons given for the visit were classified as emergent only 47% of the time.
“This underscores the difficulty physicians face in making definitive assessments at the triage level without first evaluating patients, given that a single reason for seeking care could have multiple possible underlying causes,” Ukert added. “Alternatives to discharge diagnoses are needed.”
One proposed solution is obtaining more comprehensive information from patients upon arrival, which could include their main concerns, symptoms and mode of arrival.
“This information could lead to the development of objective tools that could more accurately assess the complexity of these visits,” Ukert concluded.
The study calls for a reevaluation of current policies and suggests that enhanced patient information gathering and the development of new diagnostic tools could greatly improve the accuracy of initial medical urgency assessments in emergency departments.
Source: Texas A&M University