Study: Discharge Diagnosis No Help in Reducing Patient Emergency Room Abuse

Those hoping that employing discharge diagnoses data to patients visiting the emergency department to weed out primary care patients from those needing emergency triage will be disheartened to learn that a recent study found that as a metric, it won’t work.

The most recent issue of the Journal of the American Medical Association published a study (available free online here) that reviewed nearly 35,000 patient records and found a large majority of emergency department patients who received a discharge diagnosis of “primary care-treatable” required emergency department triage. “The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits,” wrote the study’s authors, Maria C. Raven, Robert A. Lowe, Judith Maselli, and Renee Y. Hsia.

The purpose of the study was to find an association between the emergency department presenting complaint and emergency department discharge diagnosis. The study found that 6.3 percent of the sample emergency department patients were determined in the discharge diagnosis to have primary care-treatable ailments, however the vast majority of those, 88.7 percent, came into the emergency room complaining of symptoms similar to legitimate emergency department patients. “Of these visits, 11.1 percent … were identified at ED triage as needing immediate or emergency care; 12.5 percent … required hospital admission; and 3.4 percent of admitted patients went directly from the ED to the operating room,” the study’s authors concluded.

The study pulled its data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS).

The main reason for the study was to investigate whether a hospital could “deny or limit payment” under Medicaid or similar program if an emergency room patient is diagnosed as not having an emergency condition. “Legislatures or regulators in Tennessee, Iowa, New Hampshire, and Illinois have considered or enacted legislation or regulations that would limit payment for nonemergency ED visits by Medicaid enrollees, based on discharge diagnosis,” the authors write. “Other states, including Arizona, Oregon, Illinois, Iowa, Nebraska, North Carolina, and New Mexico, have recently implemented or considered implementing some level of copayment requirement for nonemergency use of the ED.” In the state of Washington, the authors report, there was a proposal to use emergency department discharge diagnosis in making a payment determination.

“For this approach to be effective at reducing nonemergency emergency department use without discouraging emergency department use for more serious conditions, it would be necessary to predict discharge diagnosis based on information available before the patient is seen in the emergency department—i.e., based on presenting symptoms,” the authors write. The authors found little or no connection that would enable discharge diagnosis to be employed.