title: Comparison of presenting complaint vs discharge diagnosis for identifying " nonemergency" emergency department visits.
abstract: OBJECTIVE
  Reduction in emergency department (ED) use is frequently viewed as a potential source for cost savings. One consideration has been to deny payment if the patient's diagnosis upon ED discharge appears to reflect a "nonemergency" condition. This approach does not incorporate other clinical factors such as chief complaint that may inform necessity for ED care.
  
  
  OBJECTIVE
  To determine whether ED presenting complaint and ED discharge diagnosis correspond sufficiently to support use of discharge diagnosis as the basis for policies discouraging ED use.
  
  
  METHODS
  The New York University emergency department algorithm has been commonly used to identify nonemergency ED visits. We applied the algorithm to publicly available ED visit data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) for the purpose of identifying all "primary care-treatable" visits. The 2009 NHAMCS data set contains 34,942 records, each representing a unique ED visit. For each visit with a discharge diagnosis classified as primary care treatable, we identified the chief complaint. To determine whether these chief complaints correspond to nonemergency ED visits, we then examined all ED visits with this same group of chief complaints to ascertain the ED course, final disposition, and discharge diagnoses.
  
  
  METHODS
  Patient demographics, clinical characteristics, and disposition associated with chief complaints related to nonemergency ED visits.
  
  
  RESULTS
  Although only 6.3% (95% CI, 5.8%-6.7%) of visits were determined to have primary care-treatable diagnoses based on discharge diagnosis and our modification of the algorithm, the chief complaints reported for these ED visits with primary care-treatable ED discharge diagnoses were the same chief complaints reported for 88.7% (95% CI, 88.1%-89.4%) of all ED visits. Of these visits, 11.1% (95% CI, 9.3%-13.0%) were identified at ED triage as needing immediate or emergency care; 12.5% (95% CI, 11.8%-14.3%) required hospital admission; and 3.4% (95% CI, 2.5%-4.3%) of admitted patients went directly from the ED to the operating room.
  
  
  CONCLUSIONS
  Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits.
authors.affiliation: Departments of Emergency Medicine, University of California, San Francisco, CA 94707, USA. maria.raven@emergency.ucsf.edu
authors.forename: Maria C
authors.initials: MC
authors.lastname: Raven
authors.forename: Robert A
authors.initials: RA
authors.lastname: Lowe
authors.forename: Judith
authors.initials: J
authors.lastname: Maselli
authors.forename: Renee Y
authors.initials: RY
authors.lastname: Hsia
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D003625:Data Collection; D003933:Diagnosis; D004608:Eligibility Determination; D004632:Emergency Medical Services / Q000592:standards*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D019458:Insurance Coverage; D038801:International Classification of Diseases; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data*; D011320:Primary Health Care; D012720:Severity of Illness Index; D014481:United States; D055815:Young Adult