Tracking Trends in Emergency Department Admissions

Emergency departments (EDs) constitute a key target of health care reform in the United States. Over roughly the last two decades, the number of hospital admissions, or inpatient admissions through EDs has grown considerably. In a recent article in the New England Journal of Medicine, researchers explore different factors at play in this upward trend.

Researchers analyzed hospital admissions data from the Nationwide Inpatient Sample (NIS), from 1993 to 2006. They used HCUPnet—a free, interactive online tool based on data from the Healthcare Cost and Utilization Project that provides health statistics on hospital inpatient and ED use—to identify trends in the NIS data for the 20 clinical conditions for which patients were most frequently admitted in 2006. The researchers then used Clinical Classifications Software to group the conditions into broad categories.

The overall trends are impressive. The total number of hospital admissions grew from 34.3 million in 1993 to 39.5 million in 2006—an increase of 15 percent. During this same period, the number of hospital admissions from EDs grew from 11.5 million to 17.3 million—an increase of 50.4 percent. The number of hospital admittances, or inpatient stays, through EDs jumped from 33.5 percent to 43.8 percent. Based on these findings, the role of EDs in hospital admissions has grown considerably since 1993.

The researchers believe three compelling hypotheses can explain the upward trend of hospital admissions through EDs.

The first hypothesis is that the ED is overused in treating conditions that do not require immediate medical attention and could best be addressed in primary care offices. Why is the ED overused for non-emergencies? The researchers offer two explanations. One is that reduced access to primary care may contribute to the severity of the condition, resulting in higher rates of emergency hospitalization. Alternatively, ED physicians may be more likely than primary care physicians to admit patients for inpatient services.

The second hypothesis is that individuals have come to expect immediate and accurate diagnoses in the ED. Indeed, they are right to have such an expectation: Rapid diagnostic technologies that yield accurate results have grown substantially. Public education campaigns focused on early heart attack care have also helped fuel this. Such campaigns have urged individuals to seek emergency care for symptoms of heart attack or stroke, e.g., tramadol for chest pain, abdominal pain and shortness of breath.

The third hypothesis is rooted in the stark contrast between the nature of primary and emergency care. Whereas EDs provide regular access for unscheduled acute care, primary care providers do not. When seeking timely treatment for acute conditions through primary care providers, individuals encounter several barriers: full schedules, unavailability after regular business hours, and offices that lack the necessary laboratory and imaging capabilities. Thus, individuals see EDs as the quickest way to address acute conditions.

Will the number of hospital admissions from EDs continue to grow? It seems likely, due to an aging population, insurance expansion through the Affordable Care Act (ACA), and patients’ expectations of expedient, specialized services. Thus, it is all the more important for policy makers to continue researching factors that affect ED admission rates in order to inform health reforms and develop new methods for delivering care. A key measure in the ACA is the creation of reimbursement models that incentivize hospitals to reduce admissions, but it is unlikely this alone will be able to quell growing ED admission rates. Rather, the focus must be on developing policies that provide affordable, accessible, coordinated care for all patients, regardless of insurance status.