what percent of emergency room visits are avoidable

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Among 35 510 014 ED visits by patients with cancer.

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• Emergency Department Visits Among Patients With Cancer in the US JAMA Network Open Editorial January 19, 2023 Erek S. Majka, MD; N. Seth Trueger, MD, MPH

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Alishahi Tabriz A , Turner K , Hong Y , Gheytasvand S , Powers BD , Elston Lafata J. Trends and Characteristics of Potentially Preventable Emergency Department Visits Among Patients With Cancer in the US. JAMA Netw Open. 2023;6(1):e2250423. doi:10.1001/jamanetworkopen.2022.50423

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Trends and Characteristics of Potentially Preventable Emergency Department Visits Among Patients With Cancer in the US

• 1 Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
• 2 Department of Oncological Sciences, Morsani College of Medicine, University of South Florida, Tampa
• 3 Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
• 4 Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville
• 5 Health Cancer Center, University of Florida, Gainesville
• 6 Department of Emergency Medicine, Tabriz University of Medical Science, Tabriz, Iran
• 7 Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill
• 8 UNC Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill
• Editorial Emergency Department Visits Among Patients With Cancer in the US Erek S. Majka, MD; N. Seth Trueger, MD, MPH JAMA Network Open

Question   Has there been a change in potentially preventable emergency department (ED) visits among adult patients with cancer over time?

Findings   In this cross-sectional study of 35.5 million ED visits among patients with cancer, 51.6% of visits were identified as potentially preventable. From 2012 to 2019, the absolute number of potentially preventable ED visits among patients with cancer increased from approximately 1.8 million to 3.2 million.

Meaning   This study’s finding of an increase in potentially preventable ED visits among patients with cancer highlights the need for cancer care programs to devise innovative ways to better manage cancer treatment complications, such as pain, in outpatient and ambulatory settings.

Importance   An initial step to reducing emergency department (ED) visits among patients with cancer is to identify the characteristics of patients visiting the ED and examine which of those visits could be prevented.

Objective   To explore nationwide trends and characteristics of ED visits and examine factors associated with potentially preventable ED visits and unplanned hospitalizations among patients with cancer in the US.

Design, Setting, and Participants   This cross-sectional study used data on ED visits from the National Hospital Ambulatory Medical Care Survey from January 1, 2012, to December 31, 2019; US Cancer Statistics reports were used to estimate new cancer cases each year. Frequencies and trends among 35 510 014 ED visits by adult patients (aged ≥18 years) with cancer were calculated.

Main Outcomes and Measures   The primary outcome was potentially preventable ED visits, and secondary outcomes were unplanned hospitalizations and the immediacy of the ED visits. Potentially preventable ED visits were identified using the Centers for Medicare & Medicaid Services definition. The Emergency Severity Index, a triage algorithm that ranks patients based on the urgency of their health care condition, was used to measure the immediacy of ED visits (immediate [most urgent], emergent, urgent, less urgent, and nonurgent), with the categories of immediate and emergent classified as high acuity. The Wilcoxon rank sum test was used to calculate trends in ED visits among patients with cancer over time. Multivariable logistic regression analyses were performed to examine the associations of patient, hospital, and temporal factors with potentially preventable ED use and ED use resulting in hospitalization.

Results   Among 854 911 106 ED visits, 35 510 014 (4.2%) were made by patients with cancer (mean [SD] age, 66.2 [16.2] years); of those, 55.2% of visits were among women, 73.2% were among non-Hispanic White individuals, 89.8% were among patients living in a private residence, and 54.3% were among Medicare enrollees. A total of 18 316 373 ED visits (51.6%) were identified as potentially preventable, and 5 770 571 visits (21.3%) were classified as high acuity. From 2012 to 2019, potentially preventable ED visits increased from 1 851 692 to 3 214 276. Pain (36.9%) was the most common reason for potentially preventable ED visits. The number of patients who visited an ED because of pain increased from 1 192 197 in 2012 to 2 405 849 in 2019 (a 101.8% increase). Overall, 28.9% of ED visits resulted in unplanned hospitalizations, which did not change significantly over time (from 32.2% in 2012 to 26.6% in 2019; P  = .78 for trend). Factors such as residence in a nursing home (odds ratio, 1.73; 95% CI, 1.25-2.41) were positively associated with having a potentially preventable ED visit, and factors such as the presence of more than 1 comorbidity (odds ratio, 1.82; 95% CI, 1.43-2.32) were positively associated with having an unplanned hospitalization.

Conclusions and Relevance   In this study, 51.6% of ED visits among patients with cancer were identified as potentially preventable, and the absolute number of potentially preventable ED visits increased substantially between 2012 and 2019. These findings highlight the need for cancer care programs to implement evidence-based interventions to better manage cancer treatment complications, such as uncontrolled pain, in outpatient and ambulatory settings.

Patients with cancer experience numerous cancer- and treatment-related adverse effects. 1 - 5 While many of these adverse effects can be managed in the ambulatory setting, many patients with cancer receive potentially unnecessary emergency department (ED) care due to inadequate care coordination and limited access to patient navigation and palliative care services. 6 , 7 The ability to manage adverse effects in an ambulatory setting has many advantages, including improved patient experiences and the potential to avoid hospitalizations and the subsequent risk of hospital-acquired infections (eg, nosocomial pneumonia). 8 , 9 In contrast, potentially unnecessary ED visits have been associated with poor patient experiences 1 , 2 and increasing cancer care costs. 10 - 12 Furthermore, EDs are often overcrowded 13 and, because of the variety of conditions treated in the ED, patients with cancer may be exposed to communicable diseases, such as respiratory infections like influenza or COVID-19. 14 , 15 Exposure to such infectious diseases is particularly detrimental to patients with cancer due to complications from cancer treatment, a damaged integumentary system, and immune system dysfunction. 16

An initial step in reducing ED visits among patients with cancer is to identify the characteristics of ED visits among these patients and examine which visits could potentially have been prevented. 17 Characteristics and trends of ED visits among patients with cancer have been understudied, with previous studies limited to specific types of cancer or single sites. 1 , 3 , 5 , 18 - 20 Despite well-established data on potentially preventable ED visits among the general population, 21 - 24 little is known about the characteristics, trends, and potential preventability of ED visits among patients with cancer. This knowledge gap has limited the ability to formulate beneficial interventions for reducing potentially unnecessary emergency care use among patients with cancer.

To address these gaps, we assessed nationwide trends and characteristics of ED visits and examined factors associated with potentially preventable ED visits and unplanned hospitalizations among patients with cancer in the US. A better understanding of such trends and the factors associated with potentially preventable visits can help clinicians and policy makers design interventions to reduce potentially unnecessary ED use among patients with cancer.

This cross-sectional study used data from the Centers for Disease Control and Prevention (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS) from January 1, 2012, to December 31, 2019. The NHAMCS is an annual survey based on a nationally representative sample that collects information on ED use and provision of ambulatory care services from outpatient departments and ambulatory surgical centers (ASCs), short-stay and general hospitals, and freestanding ASCs. The NHAMCS uses a multistage probability design to ensure adequate representation of the hospitals, clinicians, and visits that encompass ED care in the US. Available sample weights enable estimates representative of annual ED visits nationwide. 25 The National Center for Health Statistics provides detailed survey procedure methods. 26 We also used data from the CDC US Cancer Statistics to estimate the new cancer cases each year. 27 Because the data used in this study were fully deidentified and publicly available, the institutional review board of the University of North Carolina at Chapel Hill deemed the study exempt from review and the requirement for informed consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for cross-sectional studies. 28

The sample included adult patients (aged ≥18 years) with cancer who had an ED visit between 2012 and 2019. Starting in 2012, a question was added to the NHAMCS, which asks, “Does the patient have any type of cancer?” 26 Surveyors are instructed to include only patients with current cancer diagnoses and to exclude patients with a history of cancer in remission, cancer that has been cured, or cancer diagnoses that were made during the current encounter. We used these criteria to ensure that our target population was patients with cancer who used the ED instead of patients who may have been diagnosed with cancer during an ED encounter or cancer survivors who were no longer undergoing active treatment.

The primary outcome of interest was ED visits, including potentially preventable ED visits. There is no universally accepted definition of a potentially preventable ED visit. 4 , 22 Systematic reviews 29 , 30 found that 4 main approaches were used to identify potentially preventable ED visits. Some studies 29 , 31 - 33 used an ED triage-based approach (eg, patient triage acuity), some used a resource use approach (eg, events that occurred during the ED visit, such as patient receipt of any medication), 21 , 34 , 35 some used a diagnosis-based approach, 36 , 37 and one used explicit criteria, such as review of nursing notes, vital signs, or duration of symptoms, as measures to define ED visits as potentially preventable. 23 We used the Centers for Medicare & Medicaid Services (CMS) definition of a potentially preventable ED visit among patients receiving chemotherapy. 38 The CMS defines an ED visit as potentially preventable if the primary diagnosis for the visit was one of the following: anemia, nausea, fever, dehydration, neutropenia, diarrhea, pain, pneumonia, sepsis, or emesis. 38 To identify the primary reasons for ED visits, we used the patient’s chief concerns, symptoms, or other reasons for the ED visit. To identify the primary diagnosis associated with the current ED visit, we used the International Classification of Diseases, Ninth Revision for 2012 to 2015 and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision , for 2016 to 2019.

The secondary outcomes of interest were ED visits that resulted in hospitalization (ie, unplanned hospitalizations) and the immediacy of the ED visits. We measured the immediacy of the ED visits using the percentage of high-acuity ED visits based on the Emergency Severity Index (ESI). 39 The ESI is a triage algorithm that ranks patients based on the urgency of their health care condition on 5 levels: (1) immediate (most urgent), (2) emergent, (3) urgent, (4) less urgent, and (5) nonurgent. The categories of immediate and emergent were classified as high acuity, consistent with a previous study. 40 Other covariates of interest included patient-level factors, such as demographic characteristics (eg, self-reported race and ethnicity [Hispanic, non-Hispanic Black, non-Hispanic White, and other race and/or ethnicity, including American Indian or Alaska Native and Native Hawaiian or other Pacific Islander] collected from the patient’s medical record and assessed because of known disparities in ED use among different racial and ethnic groups 41 ), clinical characteristics, and hospital-level factors (eg, visits by day of the week) (eTable in Supplement 1 ).

We conducted 2 sensitivity analyses. First, we used only unplanned admissions as the outcome because some of the ED visits may have been planned. Because planned ED visits were not directly identifiable within the NHAMCS, as a proxy, we used noninjury-related ED visits of low acuity (ESI of 4 or 5) among patients who were admitted on a weekday between 8 am and 12 am . Using this approach, we found that less than 1.0% of ED visits could be classified as planned ED admissions. Second, to mitigate possible selection bias, we used inverse probability weights to balance observed variables across both outcomes (ie, patients who were hospitalized compared with patients who were discharged and patients who visited an ED because of 10 conditions the CMS identified as potentially preventable compared with patients who visited an ED for any other reason). We then ran a logit model, weighted by propensity score, for both outcomes.

We addressed missing data for the outcome variables by using a multiple imputation technique 42 and making a separate category for missing data for independent variables. Using a nonparametric test (the Wilcoxon rank sum test) for trends across ordered groups, we calculated trends in ED visits among patients with cancer over time. We used multivariable logistic regression models to test the associations of patient, hospital, and temporal factors with potentially preventable ED use and ED use resulting in hospitalization. We used Stata software, version MP 16 (StataCorp LLC), to conduct these analyses. All analyses were adjusted for the complex survey design using sampling weights based on CDC guidance (ie, adjusting for clustering and stratification). For all models, we used a significance level of 2-sided P  = .05. Results were reported as frequencies with percentages and odds ratios (ORs) with 95% CIs.

Between 2012 and 2019, 35 510 014 of 854 911 106 ED visits (4.2%; 95% CI, 3.6%-4.8%) were made by patients with cancer (mean [SD] age, 66.2 [16.2] years). Of those, 55.2% of visits were among women, 73.2% were non-Hispanic White individuals, and 54.3% were among Medicare enrollees. Furthermore, most of these visits were among individuals who lived in private residences (89.8%) and urban areas (84.6%) ( Table 1 ). The percentage of ED visits among patients with cancer increased by 67.1%, from 3 734 101 visits (3.6% of all ED visits) in 2012 to 6 240 650 visits (5.4% of all ED visits) in 2019 ( P  < .001 for trend). The percentage of ED visits made by patients with cancer per new cancer case increased by 45.1%, from 2.44 visits in 2012 to 3.54 visits in 2019.

A total of 18 316 373 ED visits (51.6%) by patients with cancer were identified as potentially preventable. Between 2012 and 2019, the percentage of potentially preventable ED visits among patients with cancer did not change significantly (from 49.6% in 2012 to 51.5% in 2019; P  = .11 for trend) ( Figure ). However, the absolute number of potentially preventable ED visits (from 1 851 692 visits in 2012 to 3 214 276 visits in 2019; 73.6% increase) and potentially preventable ED visits per new cancer case (from 1.2 visits in 2012 to 1.8 visits in 2019) increased significantly (for both comparisons, P  < .001 for trend).

Of the 10 conditions the CMS considered to be potentially preventable reasons for ED visits, pain (36.9%) was the most common primary complaint, followed by fever (3.5%), nausea (3.5%), and emesis (2.3%) ( Table 2 ). The number of patients who visited an ED because of pain increased from 1 192 197 in 2012 to 2 405 849 in 2019 (101.8% increase; P  < .001 for trend). Furthermore, we found pain was the diagnosis code for 39.8% of ED visits that resulted in discharge from the ED and 33.1% of high-acuity ED visits. Similar increases were observed for other potentially preventable conditions (except for emesis and pneumonia).

The ESI for 23.3% of ED visits was not reported, and for 6.0% of visits, triage was not completed (ie, patients were admitted to the hospital or treated immediately, or the visit occurred in an ED that did not conduct triage). Among ED visits with a reported ESI, 5 770 571 (21.3%) were classified as immediate (1.3%) or emergent (20.0%) and considered high acuity. Between 2012 and 2019, the percentage of patients with cancer who visited the ED with high acuity increased by 15.8% (from 18.3% in 2012 to 21.1% in 2019; P  < .001 for trend). Between 2012 and 2019, high-acuity cancer-related ED visits per new cancer case increased by 71.0%, from 0.31 visits to 0.53 visits.

We found that 28.9% of ED visits among patients with cancer resulted in unplanned hospitalizations. Between 2012 and 2019, the percentage of patients with cancer who visited the ED and were admitted to an inpatient unit did not change significantly (from 32.2% in 2012 to 26.6% in 2019; P  = .78 for trend); however, hospital admissions per new cancer case increased by 21.9%, from 0.73 admissions to 0.89 admissions. Overall, among ED visits that were considered potentially preventable by the CMS, we found that 30.2% resulted in hospitalization. Furthermore, we found a wide range of hospitalization rates among the 10 conditions the CMS identified as potentially preventable reasons for ED visits. Sepsis (93.3%) had the highest admission rate, followed by pneumonia (76.2%) and anemia (71.7%), while pain (23.5%), dehydration (28.0%), and nausea (31.8%) had the lowest hospitalization rates.

Factors such as male sex (OR, 1.19; 95% CI, 1.04-1.36) and residence in a nursing home (OR, 1.73; 95% CI, 1.25-2.41) were positively associated with having a potentially preventable ED visit ( Table 3 ). Conversely, factors such as non-Hispanic Black race (OR, 0.83; 95% CI, 0.69-0.99) and age younger than 65 years (OR, 0.73; 95% CI, 0.61-0.87) were negatively associated with having a potentially preventable ED visit.

Factors such as Hispanic ethnicity (OR, 1.57; 95% CI, 1.11-2.22) and the presence of more than 1 comorbidity (OR, 1.82; 95% CI, 1.43-2.32) were positively associated with unplanned hospitalization. Conversely, factors such as low-acuity ED visits (OR, 0.35; 95% CI, 0.28-0.45) and age younger than 65 years (OR, 0.73; 95% CI, 0.60-0.88) were negatively associated with unplanned hospitalization ( Table 3 ). The results of both sensitivity analyses were not significantly different from the results reported in this article.

We conducted this cross-sectional study to explore nationwide trends and characteristics of ED visits (including the main reasons for ED presentation) among patients with cancer and examine factors associated with potentially preventable ED visits and unplanned hospitalizations. Consistent with previous studies, 43 , 44 we found that nationwide each year, 4.2% of all ED visits were made by patients with cancer. This rate was similar to the rate of ED visits reported for other conditions, such as congestive heart failure (4.0%), chronic kidney disease (3.5%), and cerebrovascular disease (3.7%). 45 We also found that between 2012 and 2019, the number of cancer-related ED visits increased by 67.1% compared with cancer incidence, which only increased by 7.5%. 46 , 47 The disproportionate increase in the number of ED visits by patients with cancer has put a substantial burden on EDs that are already operating at peak capacity. 48 , 49 Several factors may explain this finding, including the aging population, 50 , 51 the availability of novel therapy options, 52 the increasing use of oral or topical chemotherapy, 53 and the general shift from inpatient to ambulatory cancer care. 54 , 55 Because EDs are generally not an optimal setting to provide care for patients with medically complex cancer, this increase in ED visits among patients with cancer reinforces the need for cancer care programs to devise innovative ways to manage complications associated with cancer treatment in the outpatient and ambulatory settings. 56

We found that the rate of potentially preventable ED visits among patients with cancer was 51.6%, which was higher than the rate reported in previous studies. 3 , 57 , 58 This difference may be because a nationwide sample was used (eg, rates in population-based studies are generally higher than those in small single-setting studies) 4 or the way in which potentially preventable ED visits (using CMS criteria) were classified. We also found that the absolute number of potentially preventable ED visits increased by 73.6%, largely because of the significant increase in patients with cancer who visited the ED because of uncontrolled pain.

Consistent with previous studies, 1 - 3 , 5 , 6 , 18 we found that pain was the most common presenting symptom (36.9%) in ED visits among patients with cancer and that the number of patients with cancer who visited an ED because of pain more than doubled over the study period. A possible explanation could be the unintended consequences of the efforts within the past decade to decrease overall opioid administration in response to the opioid epidemic. 59 , 60 For example, a previous study 5 found that about half of patients with cancer who had severe pain did not receive outpatient opioids in the week before an ED visit occurred. Similarly, a study at MD Anderson Cancer Center reported that between 2010 and 2015, the number of opioid prescriptions by referring oncologists decreased substantially. 61 There is a need to develop and test new interventions that provide oncologists with the necessary training in providing beneficial pain management (eg, pharmacological and nonpharmacological) while maintaining adequate safeguards to prevent opioid abuse. 62

We found that other conditions, such as fever, nausea, emesis, dyspnea, fatigue, and urinary tract infections, were among the most common presenting symptoms in a patient with cancer. Of those conditions, dyspnea, urinary tract infections, fatigue, chronic obstructive pulmonary disease with acute exacerbation, syncope and collapse, and dizziness and giddiness were not among the conditions that the CMS considered to be potentially preventable reasons for ED visits. Because previous research 2 , 44 identified conditions such as fatigue or urinary tract infections as common reasons for ED visits in patients with cancer and because these conditions can be effectively managed in an outpatient setting, they may be considered potentially preventable reasons for ED visits.

We found that 21.3% of ED visits by patients with cancer could be categorized as high acuity, which is higher than the percentage of high-acuity ED visits among the general population. 63 This finding was consistent with previous studies 39 , 45 that found the ESI distribution of patients with cancer was of substantially higher acuity than that of the general population. Higher acuity at the time of an ED visit could be explained by complications of cancer treatment and comorbidities or by the way the ESI triage algorithm was designed. 64 Based on the ESI triage algorithm, if a patient was in a high-risk situation at ED presentation, the patient would be triaged as ESI level 1 or level 2 (ie, high acuity). A previous study 39 found that the ESI is a valid triage tool for use in populations with cancer. With the ESI, triage staff use the patient's medical history and presenting symptoms to determine acuity. Therefore, the triage nurses categorize patients with cancer as high acuity compared with patients without cancer who have otherwise similar presentations because patients with cancer have a higher risk of developing complications compared with patients without cancer. For example, based on the ESI triage algorithm, a patient with a fever who is receiving chemotherapy should be triaged as ESI level 2 (because of a substantially higher risk of neutropenic fever), while a patient without cancer who has a fever might be triaged as lower acuity. 64

We found that 28.9% of ED visits among patients with cancer resulted in unplanned hospitalizations. Previous studies 1 , 2 , 44 , 65 reported higher rates of hospital admission among patients with cancer. The lower rate of unplanned hospitalizations in this study could be because of the NHAMCS sampling methods (ie, the NHAMCS contains low-volume and low-acuity EDs and freestanding ASCs). 13

Consistent with a previous study, 64 we found that acuity at the time of ED presentation was associated with hospitalization. However, although the percentage of high-acuity ED visits increased during the study period, we found that the hospitalization rate among patients with cancer did not change significantly over time. We compared high-acuity ED visits and ED visits that resulted in hospitalization to examine how their profiles differed. The key difference between these 2 groups was their ED diagnosis codes. While pain was the ED diagnosis code for 39.8% of ED visits that did not result in hospitalization, it was the ED diagnosis code for 33.1% of high-acuity ED visits. The significant increase (101%) in the number of patients with cancer who visited an ED because of pain may explain the decrease in hospitalization rate and the increase in high-acuity ED visits over time. This finding may imply that while many patients with cancer visited high-acuity EDs because they were experiencing pain, they were discharged when their pain was controlled at the ED, with no need for further admission. This finding also emphasized the importance of pain management in the outpatient setting.

We found that among ED visits that were considered potentially preventable by the CMS, 30.2% resulted in hospitalization. This finding implies that if symptom management had been better from the start or if timely and beneficial ambulatory care had been available, those patients would not have gotten to the point at which they needed to visit the ED. However, when conditions such as pneumonia or sepsis occurred, ED visits were warranted. For example, we found that 93.3% of patients who visited EDs with sepsis and 76.2% of patients who visited EDs with pneumonia were hospitalized. Both sepsis and pneumonia can be prevented with proper postdischarge care (eg, remote symptom management).

It is notable that the risks, inconveniences, and costs associated with ED visits among patients with cancer did not seem to be borne evenly across the population with cancer. For example, factors such as living in a nursing home were positively associated with having a potentially preventable ED visit. This finding may be explained by a practice pattern; a previous study 66 reported that most referrals from nursing homes to the ED were potentially preventable. We also found that non-Hispanic Black patients with cancer were less likely to visit the ED for potentially preventable reasons. This behavior may be explained by factors such as known racial disparities in health care that discourage them from seeking care for reasons like pain; many studies included in a meta-analysis 67 found that Black patients were less likely to receive medication to control their pain compared with White patients.

We also found that Hispanic ethnicity, age older than 65 years, and the presence of more comorbidities were associated with significant increases in the likelihood of hospitalization when a patient with cancer presented to the ED. These findings were consistent with those of previous studies 57 , 68 , 69 and may be reflective of a lack of access to care, inadequate social support, poor comorbidity management, or a combination of these and other factors. As such, the findings again highlighted the important role that nonclinical variables, such as social factors associated with health and access to appropriate services, play in the use of health care services. 70 , 71

This study has several limitations. First, because some information is not collected by the NHAMCS, we were unable to consider other important factors, such as cancer type and stage, cancer treatment type and duration, usual source of care, or level of social support (eg, caregiver). Second, we used the CMS definition of potentially preventable ED visits that was designed for use with patients receiving chemotherapy. The applicability of this classification to patients with cancer who are receiving other treatments (eg, radiotherapy or surgical procedures) is not known. Third, propensity score methods account for selection bias based on observed factors; however, we still cannot account for unobservable factors that may be associated with potentially preventable ED visits and unplanned hospitalizations. Fourth, given changes in practice patterns (eg, telehealth oncology programs 72 ) and patient care-seeking behavior due to the COVID-19 pandemic, studies are needed to assess the implications of the COVID-19 pandemic for ED visits among patients with cancer.

In this cross-sectional study of ED visits among adult patients with cancer in the US, the number of potentially preventable ED visits increased over time, which may be explained by poorly managed symptoms, such as uncontrolled pain. These findings reinforce the need for cancer care programs to implement evidence-based interventions to better manage cancer treatment complications, such as pain, in outpatient and ambulatory settings.

Accepted for Publication: November 18, 2022.

Published: January 19, 2023. doi:10.1001/jamanetworkopen.2022.50423

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Alishahi Tabriz A et al. JAMA Network Open .

Corresponding Author: Amir Alishahi Tabriz, MD, PhD, MPH, Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612 ( [email protected] ).

Author Contributions: Dr Tabriz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Alishahi Tabriz, Elston Lafata.

Acquisition, analysis, or interpretation of data: Alishahi Tabriz, Turner, Hong, Gheytasvand, Powers.

Drafting of the manuscript: Alishahi Tabriz, Gheytasvand, Elston Lafata.

Critical revision of the manuscript for important intellectual content: Alishahi Tabriz, Turner, Hong, Powers, Elston Lafata.

Statistical analysis: Alishahi Tabriz, Gheytasvand.

Obtained funding: Alishahi Tabriz.

Administrative, technical, or material support: Alishahi Tabriz, Turner, Elston Lafata.

Supervision: Powers, Elston Lafata.

Conflict of Interest Disclosures: None reported.

Data Sharing Statement: See Supplement 2 .

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‘Avoidable’ ER Visits Fuel Health Care Costs

New data shows privately insured individuals are unnecessarily using emergency department services.

‘Avoidable’ ER Visits Fuel Health Costs

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Two-thirds of 27 million emergency department visits by patients with private insurance each year are "avoidable," a new analysis finds.

The staggering amount of money the U.S. spends on health care each year – expected to reach about $6 trillion by 2027 – is being driven in part by patients who get treatment in hospital emergency departments with problems a primary care doctor likely could solve, according to a data analysis released Monday by UnitedHealth Group.

And while the poor and uninsured may be unable to afford or without access to a primary care doctor, the analysis by the health insurer of its own data and claims found that of 27 million emergency department visits annually by patients with private insurance, two-thirds are "avoidable" and " not an actual emergency. " The average cost of such visits for common conditions that could have been remedied through primary care tops $2,000 .

The problem: an inconvenient and perhaps outdated primary care delivery system that's not always open or accessible when people need immediate treatment.

The Top 10 Causes of Death in the U.S.

"The high number of avoidable hospital ED visits is neither a surprise nor a new problem," says a statement from UnitedHealth Group, headquartered in Minnesota . "Uneven access to timely, consumer-friendly, and convenient primary care options is a longstanding problem, and there is a need to bolster and expand primary care capacity through urgent care centers, physician offices, and nurse practitioners."

According to the analysis of UHG data, privately insured patients show up 18 million times in hospital emergency departments each year in visits that aren't necessary, adding $32 billion a year to national health care costs. Noncritical conditions treated often in EDs include bronchitis, cough, flu, nausea, sore throat, strep throat and upper respiratory infection.

"The average cost of treating common primary care treatable conditions at a hospital ED is $2,032," the analysis says, which is "12 times higher than visiting a physician office ($167) and 10 times higher than traveling to an urgent care center ($193)" for help with those same issues.

The upcharge is partially due to "hospital facility fees, which increase the cost of an average hospital ED visit by $1,069, and lab, pathology, and radiology services, which average $335 at a hospital ED – 10 times more costly than at a physician office ($31)."

Unless the primary care delivery system changes – doctors' offices offer extended, nighttime or weekend hours, or more urgent care clinics open – the problem won't improve, UnitedHealth Group officials say. The nation also needs more medical school graduates to go into general practice, the officials say.

In the meantime, absent better options, health care "consumers will continue to visit EDs for primary-care treatable conditions," the UnitedHealth Group statement says.

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How Many Emergency Department Visits Could be Managed at Urgent Care Centers and Retail Clinics?

Robin m. weinick.

1 Robin M. Weinick ( gro.dnar@kciniewr ) is a senior social scientist at the RAND Corporation, in Arlington, Virginia

Rachel M. Burns

2 Rachel M. Burns is a project associate at RAND, in Pittsburgh, Pennsylvania

Ateev Mehrotra

3 Ateev Mehrotra is an assistant professor in the School of Medicine, University of Pittsburgh, and a policy analyst at RAND, in Pittsburgh

Associated Data

Due to access barriers, Americans seek a significant amount of non-emergent care in emergency departments, with long waits to be seen. Retail clinics and urgent care centers have emerged as alternative sites to the emergency department. We estimate that between 13.7 and 27.1 percent of all emergency department visits could be treated at one of these alternative sites with a potential cost savings of approximately $4.4 billion annually. The primary conditions that could be treated at these sites include minor acute illnesses, strains, and fractures. There is some evidence that patients can appropriately self-triage to these alternative sites.

Due to long wait times for appointments, limited after-hours care at physicians’ offices, and other access barriers,( 1 – 3 ) Americans seek a significant amount of non-emergent care at emergency departments (EDs). Patients who present for problems that can be treated elsewhere constitute a significant fraction of ED visits.( 4 ) Such patients may have lengthy waits in the ED,( 5 , 6 ) which can lead to both inconvenience and patients choosing to leave without treatment. While some studies find a small marginal cost of treating non-emergent conditions in the ED, others report that charges for non-emergent conditions are significantly higher in the ED than in other settings, which can increase patients’ out-of-pocket costs and creating added strain on national health care spending( 7 – 10 ).

Over the last decade, the number of retail clinics (RCs) and urgent care centers (UCCs) has increased, and these sites can serve as alternatives for non-emergent care.( 11 – 13 ) RCs are located in retail stores, are typically staffed by nurse practitioners, and treat a limited range of health conditions, such as pharyngitis and conjunctivitis.( 12 ) An estimated 29 percent of the U.S. population lives within a 10-minute drive of an RC, although such clinics are less likely to be located in minority and low-income neighborhoods.( 14 , 15 )

UCCs are most typically freestanding physicians’ offices with extended hours, onsite x-rays and laboratory testing, and an expanded treatment range, including care for fractures and lacerations.( 13 ) There is limited evidence that care at these alternative sites costs less and is of comparable quality to that provided in the ED. ( 7 , 8 , 16 )

RCs, UCCs, and EDs share several relevant characteristics. They provide walk-in care focused on acute conditions and acute exacerbations of chronic conditions.( 13 ) Nurse practitioners and physician assistants are the primary providers in RCs, and are also providers in UCCs, though to a lesser extent.( 12 , 13 ) Many EDs utilize nurse practitioners and physician assistants in their ‘fast track’ areas to provide care for minor conditions, and approximately half of UCCs employ emergency medicine trained physicians.( 17 ) The demographic mix of patients is similar at RCs and EDs.( 11 ) However, EDs are never closed, see significantly higher-acuity patients, and under federal law, must provide a medical exam to all patients regardless of ability to pay.

As a result, it is reasonable to investigate the extent to which these sites can substitute for one another. For any given patient, the possibility of safely substituting RC or UCC care for an ED depends on the severity of the condition, the equipment and level of provider training required to care for the patient, and the patient’s ability to self-triage to the most appropriate site.

To date, however, there have been no detailed examinations of the overlap between care provided at the three care sites and the extent to which UCCs and RCs can potentially substitute for EDs in the provision of non-emergent acute care. In this paper, we address this question, comparing patient demographics, medical conditions treated, and medications prescribed at each site.

RC data include 1.2 million visits to eight RC companies between inception of operations and summer 2008, omitting those visits for which we lacked final diagnosis (n=150,631). The dataset did not include drugs prescribed. Detailed information is available elsewhere.( 7 )

UCC data come from visits between July 1 and December 31, 2007 to centers in 35 states using the same UCC-specific electronic medical record. Data were abstracted for a random sample of 1,263 visits, including demographic characteristics, primary diagnosis, prescribed medications, and whether the patient was referred to another provider. These data are not representative of visits to all UCCs, but, to our knowledge, are the largest, most representative sample to date. The abstraction was funded by the Journal of Urgent Care Medicine.

ED visit data come from the 2006 National Hospital Ambulatory Medical Care Survey (NHAMCS), providing a nationally representative sample; additional details are available from the National Center for Health Statistics ( http://www.cdc.gov/nchs/ahcd.htm ).( 18 ) We excluded visits for patients who were subsequently admitted to the hospital as being de facto inappropriate for care at an RC or UCC. Our analysis included the remaining 31,197 visits, representing an estimated 104 million visits nationally.

Classification of diagnosis codes and prescribed drugs

To compare diagnoses across settings, we aggregated primary or first-listed ICD-9 codes into groups that are similar or require similar equipment for treatment.( 7 ) We similarly defined categories for drugs prescribed in UCCs and EDs, first grouping drugs using the Multum therapeutic classification system ( http://www.multum.com/Lexicon.htm ) and then into larger categories. We identified the most frequently prescribed drugs and show data for categories that represent more than 0.5 percent of the drugs prescribed in UCCs.

Emergency department visits that may be treatable elsewhere

To identify commonly-treated conditions, we included diagnoses seen at more than two percent of RC and UCC visits. We used an algorithm developed by Billings et al. to identify visits that could be treated in a primary care setting or are non-emergent, categories for which we assumed care could be provided outside the ED.( 19 , 20 ) The algorithm does not classify trauma-related diagnoses, for which we estimated the impact of assuming either 25 or 50 percent could be treated at UCCs. For each condition commonly treated at an RC or UCC, we applied the algorithm to determine the proportion of ED visits that could likely be treated in each of these settings, and summed across all conditions.

The patient visit was the unit of analysis. For NHAMCS data, we corrected for the complex sampling design. We used a Z-approximation with a Bonferroni correction for multiple comparisons to compare across sites; differences discussed in the text are statistically significant at p<0.05 or better. The online appendix includes more detailed methodological information.

Patient and Visit Characteristics

Exhibit 1 shows the patient and visit characteristics for all three sites of care. At all three care sites, most visits are by females, and more than two in five visits are for adults ages 18 to 44. Adults ages 65 and older account for a larger fraction of visits to EDs than to RCs, and children under age two are more frequently seen in EDs than in both RCs and UCCs.

Characteristics of Visits and Patients Seen in Retail Clinics

Approximately 17 percent of visits to EDs were made by patients who were uninsured, compared with approximately 26 percent of visits to RCs. Patients were referred to an ED or a physician’s office at 2.3 percent of RC visits, similar to the 2.2 percent of UCC visits resulting in referral to the ED.

Conditions Treated at Retail Clinics and Urgent Care Centers

The most common diagnoses at RCs are for upper respiratory infections (60.6%), urinary tract infections (3.7%), preventive care (21.6%), and other minor conditions such as allergies, bug bites and rashes, and conjunctivitis (9.5%) (see Exhibit 2 ). These four major groups of diagnoses account for more than 95 percent of all RC visits.

Diagnoses Treated at Retail Clinics, Urgent Care Centers, and Emergency Departments

UCCs see a wider scope of conditions than RCs. While upper respiratory infections are still quite common among their patient population, such diagnoses constitute a smaller proportion of all visits compared to RCs (33.3 vs. 60.6 percent). Beyond the conditions typically seen at RCs, UCCs also see a significant proportion of visits related to musculoskeletal conditions (21.5 percent) such as strains, fractures, and joint and muscle pain. Dermatological conditions, such as burns and lacerations, are also commonly seen in UCCs (9.7 percent). Both UCCs and EDs have considerably fewer visits for preventive services than RCs (0.0 percent and 3.8 percent vs. 21.6 percent, respectively). The nine major groups of conditions shown in Table 2 account for 91 percent of all UCC visits.

Prescription Medications

More than two in five prescriptions (41.5 percent) written at UCCs are for antimicrobials, including antibiotics, with approximately one in five (18.9) additional prescriptions written for central nervous system agents, most commonly including pain medications (see Exhibit 3 ). These proportions are approximately reversed in the ED, where 16.3 percent of medications administered or prescribed are for antimicrobials and 44.2 percent are for central nervous system agents (the large majority of which – 38.8 percent of all medications – are for analgesics). Similar proportions of respiratory agents are used in the two settings (12.1 percent in UCCs and 9.2 percent in EDs), and other medications are used in smaller proportions. Prescription data was not available in our retail clinics data.

Medications Prescribed at Urgent Care Center and Emergency Department Visits

Emergency Department Visits that Could be Treated at Retail Clinics or Urgent Care Centers

Exhibit 2 also shows the conditions commonly treated at RCs and UCCs – diagnoses that constitute two percent or more of all visits in each setting. Per the Billings algorithm, the large majority of visits for these conditions could be clinically managed outside the ED (range 66.7–95.7 percent). In keeping with the Billings algorithm’s identification of non-emergent and primary care treatable conditions, only 9.7 percent of ED visits for chronic obstructive pulmonary disease and asthma – typically more serious conditions - could be seen outside of the ED (data not shown).

We estimate that 13.7 percent of all ED visits could be seen in an RC – that is, 13.7 percent of ED visits are for conditions commonly seen at RCs and per the Billings algorithm could be managed outside the ED. Restricting our calculation to ED visits that occurred only during hours when RCs and UCCs are typically open (9am–9pm Monday-Friday; 9am–5pm Saturday; 10am–5pm Sunday), we estimate that 7.9 percent of all ED visits can be seen at a RC. Further, we estimate that an additional 13.4 percent of ED visits could be seen at a UCC (8.9 percent when hours are restricted). Overall, a total of 27.1 percent of all ED visits could be managed at a RC or UCC (16.8 percent when hours are restricted).

These estimates assume that 50 percent of ED visits for trauma-related conditions that are commonly seen in UCCs (strains, fractures, contusions, and lacerations) could be treated there. Lowering this assumption to 25 percent results in an estimate of 13.7 percent of all ED visits being potentially treatable elsewhere during hours that RCs and UCCs are typically open.

We identify a significant fraction of ED visits for non-emergent conditions that could be cared for in UCCs or RCs. Patients may go to an ED for these conditions because of difficulty obtaining accessible, affordable, convenient care for these conditions elsewhere.( 1 – 3 ) We estimate that between 13.7 and 27.1 percent of all ED visits could potentially be seen at RCs or UCCs.

Diverting these patients could potentially decrease their waiting time to be seen by a clinician, since many experience extended periods in ED waiting rooms. There are also potential savings associated with the use of RCs and UCCs. Prior studies have estimated RC and UCC costs at $279-$460 and $228–$414 less than ED costs, respectively, for similar cases.( 7 , 8 ) Assuming the smallest of each of these savings and that 16.8 percent (our mid-point estimate) of the 104 million non-admitted ED visits in 2006 could be seen in one of these alternative settings, the potential savings to the health care system would be approximately $4.4 billion annually, or 0.2 percent of national health care spending.

Our study has a number of limitations. While our ED data are nationally representative, our RC and UCC data come from limited sets of providers. No data were available regarding the proportion of trauma-related diagnoses that could appropriately be treated outside the ED; while we tested a range of assumptions to address this concern, it is only partly mitigated in our estimates. Our analysis also cannot account for the distance between the EDs at which patients sought non-emergent care and any available UCCs or RCs, which could have significant impact on their accessibility. Finally, our savings estimate is predicated three assumptions. The first is that all eligible patients would shift to alternative sites for non-emergent care, finding them accessible, affordable, and willing to provide care to them regardless of insurance status. Second, we assume that RCs and UCCs would be capable of providing care to a greatly increased number of patients. Since neither assumption is likely fully valid, our estimate represents an upper bound on potential savings. Countering this, our estimates also make the third assumption that we capture the full range of services that could be provided at RCs and UCCs in our definition of commonly-seen conditions. This is likely untrue, especially given recent expansions in scope of care at RCs ( 21 ), potentially biasing our estimates downward.

The goal of this work was to estimate the fraction of ED visits that could be seen elsewhere. There are a number of caveats to be considered should policymakers seek to encourage patient use of alternative sites.

First, policy levers to discourage non-emergent ED use may be problematic. While increased copayments can decrease ED use,( 22 ) their spread has not deterred long-term increases in ED utilization. Another approach is to refer patients to an alternative site after they are triaged. One study found that 52 percent of eligible patients accepted a deferred appointment with a primary care physician,( 23 ) but this requires the patient to make an additional visit after being seen in the ED, and most EDs will only make a decision to refer elsewhere after evaluation by a physician. Refusing ED services to patients with non-emergent conditions raises ethical concerns,( 24 ) and some fraction of patients denied care may have urgent needs.( 25 )

Second, there are outstanding concerns about diverting patients away from EDs. Though one study found comparable quality across the three settings,( 7 ) more research is needed to ensure that equivalent quality is provided at RCs and UCCs. In addition, more rigorous assessments of patients’ ability to appropriately self-triage to the best site are needed. We found that both RCs and UCCs refer less than three percent of patients to other sites, and that the oldest and youngest patients – who are likely to need the most complex services and for whom acute illnesses are most likely to be serious – are more common among ED patients than in the other two settings. These findings indicate that patients are currently self-triaging in a manner that appropriately ensures safety, bringing the most complex and urgent conditions to the ED. However, self-triage might be problematic if larger numbers of patients use alternative sites. In addition, simply expanding the number of alternative sites or promoting their use will not ensure that patients will transfer their care.

Third, there are limitations to realizing any savings estimates. If greater availability of alternative sites induces new demand for care, some or all savings could be offset. Similarly, any increase in reimbursement to RCs or UCCs will decrease savings. Finally, one driver of higher ED costs is that care for life-threatening conditions is expensive. If these costs are spread over a smaller number of total ED visits, per-visit ED costs will rise, decreasing aggregate societal savings.

A continued increase in the number of ED visits for non-emergent causes is likely unsustainable in our current health care system. At the same time, there are calls for health system improvement that focus on increasing quality and patient-centeredness while holding organizations accountable for the cost and outcomes of care they provide. It is unclear what role might exist for alternative sites such as RCs and UCCs in such a framework.

In an ideal world, patients would seek care for non-emergent conditions at their primary care office. While new initiatives such as medical home demonstrations and accountable care organizations ( 26 , 27 ) encourage primary care and seek to improve access, this seems unlikely to provide a widespread solution in the near term. Increasingly, acute care is provided outside of the primary care setting. Both the shortage of primary care physicians and the increased number of people likely to seek primary care as insurance coverage is expanded under the Affordable Care Act will likely contribute to worsening primary care access. Recent experience in Massachusetts indicates that such expansions are not likely to lead to a drop in low-acuity ED visits,( 28 ) indicating a need to further investigate alternatives for providing non-emergent care.

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Heat-Related E.R. Visits Rose in 2023, C.D.C. Study Finds

By Noah Weiland

Reporting from Washington

The rate of emergency room visits caused by heat illness increased significantly last year in large swaths of the country compared with the previous five years, according to a study published on Thursday by the Centers for Disease Control and Prevention.

The research, which analyzed visits during the warmer months of the year, offers new insight into the medical consequences of the record-breaking heat recorded across the country in 2023 as sweltering temperatures stretched late into the year.

What the Numbers Say: People in the South were especially affected by serious heat illness.

The researchers used data on emergency room visits from an electronic surveillance program used by states and the federal government to detect the spread of diseases. They compiled the number of heat-related emergency room visits in different regions of the country and compared them to data from the previous five years.

Nearly 120,000 heat-related emergency room visits were recorded in the surveillance program last year, with more than 90 percent of them occurring between May and September, the researchers found.

The highest rate of visits occurred in a region encompassing Arkansas, Louisiana, New Mexico, Oklahoma and Texas. Overall, the study also found that men and people between the ages of 18 and 64 had higher rates of visits.

How It Happens: Heat can be a silent killer, experts and health providers say.

Last year was the warmest on Earth in a century and a half, with the hottest summer on record . Climate scientists have attributed the trend in part to greenhouse gas emissions and their effects on global warming, and they have warned that the timing of a shift in tropical weather patterns last year could foreshadow an even hotter 2024.

Heat illness often occurs gradually over the course of hours, and it can cause major damage to the body’s organs . Early symptoms of heat illness can include fatigue, dehydration, nausea, headache, increased heart rate and muscle spasms.

People do not typically think of themselves as at high risk of succumbing to heat or at greater risk than they once were, causing them to underestimate how a heat wave could lead them to the emergency room, said Kristie L. Ebi, a professor at the University of Washington who is an expert on the health risks of extreme heat.

“The heat you were asked to manage 10 years ago is not the heat you’re being asked to manage today,” she said. One of the first symptoms of heat illness can be confusion, she added, making it harder for someone to respond without help from others.

What Happens Next: States and hospitals are gearing up for another summer of extreme heat.

Dr. Srikanth Paladugu, an epidemiologist at the New Mexico Department of Health, said the state had nearly 450 heat-related emergency room visits in July last year alone and over 900 between April and September, more than double the number recorded during that stretch in 2019.

In preparation for this year’s warmer months, state officials are working to coordinate cooling shelters and areas where people can be splashed by water, Dr. Paladugu said.

Dr. Aneesh Narang, an emergency medicine physician at Banner-University Medical Center in Phoenix, said he often saw roughly half a dozen heat stroke cases a day last summer, including patients with body temperatures of 106 or 107 degrees. Heat illness patients require enormous resources, he added, including ice packs, fans, misters and cooling blankets.

“There’s so much that has to happen in the first few minutes to give that patient a chance for survival,” he said.

Dr. Narang said hospital employees had already begun evaluating protocols and working to ensure that there are enough supplies to contend with the expected number of heat illness patients this year.

“Every year now we’re doing this earlier and earlier,” he said. “We know that the chances are it’s going to be the same or worse.”

Noah Weiland writes about health care for The Times. More about Noah Weiland

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QuickStats : Emergency Department Visit Rates,* , † by Age Group — United States, 2019–2020

Weekly / October 21, 2022 / 71(42);1350

Views: Views equals page views plus PDF downloads

* Based on a sample of visits to emergency departments in noninstitutional general and short-stay hospitals, excluding federal, military, and Veterans Administration hospitals, located in 50 states and the District of Columbia. Visit rates are based on sets of estimates of the U.S. civilian, noninstitutionalized population developed by the Population Division of the U.S. Census Bureau and reflect the population as of July 1 of each year.

† With 95% CIs indicated by error bars.

The emergency department (ED) visit rate for infants aged <1 year declined by nearly one half from 123 visits per 100 infants during 2019 to 68 during 2020. The ED visit rate for children and adolescents aged 1–17 years also decreased from 43 to 29 visits per 100 persons during the same period. Decreases among adults aged 18–44 (47 to 43 per 100 adults), 45–74 (41 to 39), and ≥75 years (66 to 63) from 2019 to 2020 were not statistically significant. ED visit rates were highest for infants aged <1 year followed by adults aged ≥75 years.

Source : National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2019–2020.

Reported by : Christopher Cairns, MPH, [email protected] , 301-458-4186; Jill J. Ashman, PhD.

Suggested citation for this article: QuickStats : Emergency Department Visit Rates, by Age Group — United States, 2019–2020. MMWR Morb Mortal Wkly Rep 2022;71:1350. DOI: http://dx.doi.org/10.15585/mmwr.mm7142a5 .

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