Breaking Down the Growth in Emergency Department Visits

A trio of recent studies pulls back the curtain on the growing number of emergency department visits in the United States, revealing how presenting symptoms, geographical location, and insurance coverage (or the lack thereof) influence usage.

New data from the Centers for Disease Control (CDC) show that emergency department visits overall were at an all-time high in 2016, the most recent year of available data. Compared to 2015 data, ED visits rose by around 10 million patients, at nearly a 7 percent increase, bringing the total 2016 ED visits to 145.6 million.

For both years, the majority of emergency care (60 percent) was rendered outside traditional “business hours” (8am-5pm), leaving around 40 percent of care delivered during traditional business hours, presumably when other less expensive options might have been available.

“Emergency physicians are uniquely qualified to provide essential care that patients can’t get anywhere else,” said Vidor Friedman, MD, FACEP, president of the American College of Emergency Physicians (ACEP), in a prepared statement. “Nearly two-thirds of visits occur after business hours, when other doctors’ offices are closed. Millions of patients rely on emergency physicians for rapid diagnosis and treatment of acute illness, while emergency departments are increasingly viewed as a hub for care and care transitions.”

The study also showed that wait times in the ED fell, with nearly 40 percent of ED patients waiting fewer than 15 minutes.

Presenting Symptoms

Conditions that bring patients to the ED also are shifting, with the number of patients presenting with nonurgent medical symptoms falling from 5.5 percent in 2015 to 4.3 percent in 2016, according to the CDC study.

Illness brings people to the ED more often than injury. In 2016, 12.5 million patients presented with stomach pain (8.6 percent) and 7.5 million with chest pain (5.2 percent), two of the top reasons patients seek emergency care. Injuries in general accounted for a total of 42.2 million emergency visits (29 percent), with falls and motor vehicle crashes among the leading causes. Mental illness also plays a role in who visits the ED. More than 5.5 million patients visited the ED in 2016 with a primary diagnosis of mental disorder. Of those, 2.4 million visits involved a mental health professional seeing a patient in the emergency department.

“Emergency care is growing more complex and some of the larger trends that will impact emergency department planning and resource discussions include the rising number of elderly patients, preventing and treating opioid abuse and the role of the emergency department in treating and managing patients with mental illness,” Friedman said.

Location, Location, Location

Another cross-sectional study of National Hospital Ambulatory Medical Care Survey data, published in JAMA Network Open, showed that from 2005 to 2016, rural ED visit rates increased by more than 50 percent, from 36.5 to 64.5 per 100 persons, outpacing urban ED visit rates, which increased from 40.2 to just 42.8 visits per 100 persons.

That translates into an overall increase of rural ED visits from 16.7 million to 28.4 million while urban visits increased from 98.6 million to 117.2 million, according to researchers from the University of New Mexico, Albuquerque and the University of Michigan. Those gains are further reflected in increases of rural ED use among non-Hispanic white patients, ages 18 to 64, Medicaid beneficiaries and patients without insurance.

“Rural EDs are increasingly serving as safety-net hospitals, potentially further destabilizing their budgets because they generally operate in the traditional fee-for-service model,” the study’s authors concluded.

Who’s Got You Covered?

Though the number of uninsured patients has risen by around 3 percent over the past two years and rural EDs saw an increase in uninsured patients from 2005 to 2016, that’s not the trend overall for ED visits, at least not through 2016.

According to another recent study published in JAMA Network Open and authored by members of the department of emergency medicine at the Renaissance School of Medicine, Stony Brook University and US Acute Care Solutions, the percentage of uninsured patients treated in hospital emergency departments fell from 16 percent in 2006 to 8 percent in 2016. ED visits by uninsured patients between the ages of 18 and 64 dropped even more significantly, from 20 percent in 2006 to 11 percent in 2016.

Given that the greatest drop in uninsured ED visits occurred between 2013 and 2016, the study’s authors, who reviewed 1.4 billion ED visits, pointed to the Affordable Care Act (ACA), along with other payment reform efforts, as the likely causes for the decrease. The ACA also is the likely cause of an increase in Medicaid patient visits during the same time period, since the study found only a small increase in Medicaid use from 2006 to 2013, then increases of 3.3 percent each year from 2013 to 2016.

One thing the ACA has not done, however, according to results of this and all the studies cited, is reduce the overall number of ED visits, which may point to a number of complicating factors in our current healthcare system.

“I think at the end of the day my question would be, do you have access to care because of insurance, or are there still financial impediments to that process,” said Dr. Rade Vukmir, spokesman for ACEP, in an article by Modern Healthcare. “If you look around you’ll find that there may be.”

For more information about trends in ED usage in the United States, review the following resources, which were helpful in compiling this article: