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19-03-2013 | Emergency medicine | Article

Presenting symptoms belie ED discharge diagnoses


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medwireNews: Presenting symptoms among patients in the emergency department (ED) do not differ between those who need hospital treatment and those who could have been treated in primary care, a study in JAMA shows.

In a related editorial, James Adams (Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA) says the findings indicate that "intuitive, oversimplified, yet enduring beliefs about nonurgent patients in the ED should be abandoned," and warns against denying Medicaid reimbursement for ED visits that are perceived as unwarranted.

"Because the presenting complaints of patients who are ultimately recognized to have nonurgent conditions overlap so extensively with the presenting complaints of those with more severe conditions, it is not possible to justify denial of payment based on final diagnosis," he says.

Moreover, patients diagnosed with a complaint that could have been treated within primary care comprised just 6.3% of the 34,942 records obtained from the 2009 National Hospital Ambulatory Medical Care Survey. This indicates that withholding payment for such claims would not save much money, says Adams.

The researchers, led by Maria Raven (University of California, San Francisco, USA), identified 2212 ED cases where patients could have been treated in primary care, and 30,827 cases that were not emergent, but whose diagnosis and treatment required resources not available in primary care (nonemergency cases).

The major presenting symptoms of patients with primary-care-treatable diagnoses were the same as those reported for 88.7% of the nonemergency ED visits, with 76.8% of patients having at least one abnormal vital sign. The abnormal signs were very often respiratory rate or blood pressure; however, 16.1% of patients had an abnormal heart rate and 3.7% had abnormal pulse oximetry, and 6.6% were triaged as needing immediate or emergent care.

Despite having presenting symptoms similar to those of patients who could have been treated in primary care, 12.5% of patients with nonemergency conditions were admitted to the hospital, with 11.2% of this group admitted to critical care and 3.4% taken to the operating room.

In his editorial, Adams suggests that efforts to reduce ED expenditure should focus on patients who generate the highest costs through repeat ED visits, who often have "complex underlying medical, social, and psychiatric conditions."

By Eleanor McDermid, Senior medwireNews Reporter

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