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National Center for Health Statistics (US). Health, United States, 2012: With Special Feature on Emergency Care. Hyattsville (MD): National Center for Health Statistics (US); 2013 May.

Cover of Health, United States, 2012

Health, United States, 2012: With Special Feature on Emergency Care.

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Special Feature on Emergency Care

Introduction

Hospital emergency medical services are an integral part of the American health care system. Emergency departments provide care for patients with emergency health care needs. There were 130 million emergency department visits in 2010, accounting for about 4% of all health care spending in the United States (1,2). Today, emergency departments also must be prepared to handle a surge in patients in the event of major casualty situations such as natural disasters, terrorist attacks, multivehicle accidents, and disease outbreaks. In addition, emergency departments can be a safety net provider for patients without an alternative place of care, and a source of care after regular office hours of other health care providers (36).

Several laws affect the role that emergency departments play in the health care system. The Emergency Medical Treatment and Labor Act obliges emergency departments to stabilize patients, regardless of ability to pay (35,7). The Balanced Budget Act of 1997 requires certain Medicare and Medicaid managed care plans to pay for emergency care that a reasonable person would consider necessary. Many states also have adopted a “prudent layperson” standard, requiring managed care organizations and insurers to cover emergency department visits if a layperson with average medical knowledge would have viewed their symptoms as serious (5,8).

Although the percentage of Americans visiting the emergency department each year is stable, the total number of visits to emergency departments increased 34% between 1995 and 2010 (from 97 million to 130 million visits; Table 88). The visit rate—which accounts for changes in population over time—has increased 16%, from 37 visits per 100 persons in 1995 to 43 visits in 2010. At the same time, the supply of emergency departments has declined by about 11% to 3,700 emergency departments in 2010 (9).

Given this increase in demand for emergency department care and the reduction in the number of emergency departments, concerns have been raised about crowding in emergency departments. Commonly used indicators of crowding are ambulance diversions, boarding of patients in hallways, and long patient wait times and walkouts (36,10,11). Emergency department crowding is of concern because of the burden it places on emergency department staff and resources. In addition, treatment delays that result from crowding may reduce quality of care and patient satisfaction and result in poorer clinical outcomes, in some cases including higher risk of death (3,5,6,1013).

The impact of crowded conditions, and the success of efforts to improve patient flow and reduce crowding, depend on who uses the emergency department and why. Each year, about 20% of Americans visit the emergency department at least once. Emergency department use is more likely among the poor, those in fair or poor health, the elderly, infants and young children, and those with Medicaid coverage (4,1417). Among those who use the emergency department, some patients make multiple emergency department visits annually. One analysis found that high users (defined as four or more visits in 2 years) represented only 1% of users but accounted for 18% of emergency department visits (18). These frequent users were more likely to be elderly, poor, have chronic conditions, and be in poor health.

Patients’ decisions to visit an emergency department are based on a variety of factors, including insurance status, their perception about the urgency of their condition, and available sources of health care (4,19). Although emergency departments are designed to provide emergency care, patients cannot always evaluate the severity of their condition and may view nonurgent complaints as emergencies. Some patients may use the emergency department for primary care services, but research suggests that emergency departments are not ideal locations for primary care because of the lack of continuity, coordination of care, and follow-up, as well as poor patient satisfaction due to long wait times in the emergency department. Because emergency departments may lack a medical history for the patient, they may run unnecessary tests (19). Further, emergency department care is usually more costly than care in physician offices and other outpatient care settings (20,21). On average, an emergency department visit for a nonemergency condition costs seven times more than a community health center visit (22).

This Special Feature explores emergency care in the United States. Data are presented on who uses the emergency department, why they visit the emergency department, what happens there, and how much emergency department visits cost. Trends in emergency department use in the past year by age and insurance coverage are shown, along with the reasons people visit the emergency department, injury-related visits, wait times to see a physician, and the urgency of visits. Information on the use of x-rays and more-advanced scanning techniques gives insight into services provided in the emergency department. To better understand what happens after the emergency department visit, the discharge status of visits and the types of drugs prescribed at discharge are examined. Finally, the cost of emergency department visits is shown. This collection of charts provides an overview of hospital emergency medical services in the United States.

References

1.
CDC/NCHS National Hospital Ambulatory Medical Care Survey. [unpublished analysis]. For more information, visit: http://www​.cdc.gov/nchs/ahcd.htm.
2.
Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost Trends, Medical Expenditure Panel Survey. [unpublished analysis]. For more information, visit: http://meps​.ahrq.gov/mepsweb/
3.
Institute of Medicine. Hospital-based emergency care: At the breaking point. Washington, DC: National Academies Press; 2007. Available from: http://www​.nap.edu/openbook​.php?record_id​=11621&page=1.
4.
DeLia D, Cantor J. Emergency department utilization and capacity. Princeton, NJ: Robert Wood Johnson Foundation, The Synthesis Project; 2009. Research Synthesis Report no. 17. Available from: http://www​.rwjf.org/content​/dam/farm/reports​/reports/2009/rwjf43565.
5.
Taylor J. Don’t bring me your tired, your poor: The crowded state of America’s emergency departments. Washington DC: National Health Policy Forum; 2006. Issue Brief no. 811. Available from: http://www​.nhpf.org/library​/issue-briefs​/IB811_EDCrowding_07-07-06.pdf. [PubMed: 16845759]
6.
Government Accountability Office. Hospital emergency departments: Crowding continues to occur, and some patients wait longer than recommended time frames. Washington, DC: GAO; 2009. Pub no. GAO–09-347. Available from: http://www​.gao.gov/new.items/d09347.pdf.
7.
Kellerman AL, Martinez R. Perspective: The ER, 50 years on. N Engl J Med. 2011;364(24):2278–9. [PubMed: 21675886]
8.
Derlet RW, Ledesma A. How do prudent laypeople define an emergency medical condition? J Emerg Med. 1999;17(3):413–8. [PubMed: 10338230]
9.
American Hospital Association. Health Forum, AHA Annual Survey of Hospitals. [unpublished analysis]. For more information, visit: http://www​.ahasurvey​.org/taker/asindex.do.
10.
Burt CW, McCaig LF. Advance data from vital and health statistics no 376. Hyattsville, MD: NCHS; 2006. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003–04. Available from: http://www​.cdc.gov/nchs/data/ad/ad376​.pdf. [PubMed: 17037024]
11.
ACEP Boarding Task Force. Emergency department crowding: High-impact solutions. Irving, TX: American College of Emergency Physicians; 2008. Available from: http://www​.acep.org/workarea​/DownloadAsset.aspx?id=50026.
12.
Cardoso LT, Grion CM, Matsuo T, Anami EH, Kauss IA, Seko L, Bonametti AM. Impact of delayed admission to intensive care units on mortality of critically ill patients: A cohort study. Crit Care. 2011;15(1):1–8. [PMC free article: PMC3222064] [PubMed: 21244671]
13.
Hsia RY, Tabas JA. Emergency care: The increasing weight of increasing waits. Arch Intern Med. 2009;169(20):1836–8. [PubMed: 19901134]
14.
Xu KT, Nelson BK, Berk S. The changing profile of patients who used emergency department services in the United States: 1996 to 2005. Ann Emerg Med. 2009;54(6):805–10. [PubMed: 19811852]
15.
Cunningham PJ. What accounts for differences in the use of hospital emergency departments across U.S. communities? Health Aff (Millwood). 2006;25(5):w324–36. [PubMed: 16849363]
16.
Garcia TC, Bernstein AB, Bush MA. NCHS Data Brief no. 38. Hyattsville, MD: NCHS; 2010. Emergency department visitors and visits: Who used the emergency room in 2007? Available from: http://www​.cdc.gov/nchs​/data/databriefs/db38.pdf. [PubMed: 20487622]
17.
Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997–2007. JAMA. 2010;304(6):664–70. [PMC free article: PMC3123697] [PubMed: 20699458]
18.
Peppe EM, Mays JW, Chang HC, Becker E, DiJulio B. Characteristics of frequent emergency department users. Menlo Park, CA: Kaiser Family Foundation; 2007. Available from: http://www​.kff.org/insurance​/upload/7696.pdf.
19.
Cunningham PJ, May JH. Insured Americans drive surge in emergency department visits. Washington, DC: Center for Studying Health System Change; 2003. Issue Brief no. 70. Available from: http://www​.hschange.com/CONTENT/613/ [PubMed: 14577417]
20.
Felland LE, Hurley RE, Kemper NM. Safety net hospital emergency departments: Creating safety valves for non-urgent care. Washington, DC: Center for Studying Health System Change; 2008. Issue Brief no. 120. Available from: http://www​.hschange.com/CONTENT/983/ [PubMed: 18478670]
21.
Machlin S, Chowdhury S. Expenses and characteristics of physician visits in different ambulatory care settings, 2008. Rockville, MD: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey; 2011. Statistical Brief no. 318. Available from: http://meps​.ahrq.gov​/mepsweb/data_files/publications​/st318/stat318.pdf.
22.
Government Accountability Office. Hospital emergency departments: Health center strategies that may help reduce their use. Washington, DC: GAO; 2011. Pub no. GAO-11-414R. Available from: http://www​.gao.gov/assets/100/97416.pdf.

Emergency Department Use, by Age

In 2011, 20% of persons reported one or more emergency department visits in the past year and 7% reported two or more emergency department visits.

In 2011, one in five people reported visiting the emergency department at least once in the past year. Reported use was highest among children under age 6 years (24%) and for adults aged 75 and over (27%). The percentage of adults aged 18–64 and aged 65–74 reporting at least one visit was similar, at 20%. At least one emergency department visit in the past year was reported for 16% of children aged 6–17.

The percentage of those reporting two or more emergency department visits in the past year was substantially lower, at 7% in 2011. Repeated emergency department use was higher among young children and older adults (9%). Seven percent of adults aged 18–64 and aged 65–74 reported two or more emergency department visits in the past year. Repeated emergency department use was lowest for children aged 6–17, at 5%.

During 2001 through 2011, the percentage of persons with at least one emergency department visit in the past year was stable at 20%–22% (see data table for Figure 20). Throughout that time period, emergency department use was higher among young children and older adults. Use was stable for all age groups except for school-aged children aged 6–17, for whom there was a decline in emergency department use from 19% in 2010 to 16% in 2011.

Figure 20 consists of two bar graphs, one showing one or more emergency department visits and one showing two or more emergency department visits, within the past 12 months, by age group, for 2001 and 2011.

Figure 20Emergency department visits in the past 12 months, by age: United States, 2001 and 2011

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2012.htm#fig20

NOTE: See data table for Figure 20.

SOURCE: CDC/NCHS, National Health Interview Survey. See Appendix I, National Health Interview Survey (NHIS).

Emergency Department Use, by Insurance Coverage

During the past decade, both children and adults aged 18–64 with Medicaid coverage were more likely to have at least one emergency department visit in the past year, compared with the uninsured and those with private coverage.

In 2011, 24% of children with Medicaid had at least one emergency department visit in the past year, compared with 15% of children with private insurance and 14% of children without insurance. Among adults aged 18–64, 38% of those with Medicaid had at least one emergency department visit in the past year, compared with 16% of those with private insurance and 21% of adults without insurance.

During 2001 through 2010, the percentage of persons with at least one emergency department visit in the past year was 20%–22% for children and 19%–21% for working-age adults. Throughout the period, children and adults aged 18–64 with Medicaid were more likely than the uninsured or those with private insurance to have at least one emergency department visit.

Between 2010 and 2011, however, there was a decline in emergency department use in the past year for children in all insurance groups. There was a 13% decline in the percentage with at least one emergency department visit in the past year among children with private health insurance, 19% for those with Medicaid, and 29% for the uninsured. Among adults aged 18–64, emergency department use remained stable between 2010 and 2011 for the uninsured and those with Medicaid but declined 10% for those with private insurance.

Emergency department use is related to many factors, including health status, alternative sources of care, and insurance coverage (17). Persons with Medicaid may be sicker than the rest of the population and may find it more difficult to locate other sources of care, and these factors may be reflected in higher emergency department use among adults and children with Medicaid coverage (1,4,8).

Figure 21 consists of two line graphs, one for children under age 18 and one for adults aged 18 to 64, showing one or more emergency department visits within the past 12 months, by type of health insurance coverage, for 2001 through 2011

Figure 21One or more emergency department visits in the past 12 months, by age and type of coverage: United States, 2001–2011

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2012.htm#fig21

NOTE: See data table for Figure 21.

SOURCE: CDC/NCHS, National Health Interview Survey. See Appendix I, National Health Interview Survey (NHIS).

References

1.
DeLia D, Cantor J. Emergency department utilization and capacity. Princeton, NJ: Robert Wood Johnson Foundation, The Synthesis Project; 2009. Research Synthesis Report no. 17. Available from: http://www​.rwjf.org/content​/dam/farm/reports​/reports/2009/rwjf43565.
2.
Garcia TC, Bernstein AB, Bush MA. NCHS Data Brief no. 38. Hyattsville, MD: NCHS; 2010. Emergency department visitors and visits: Who used the emergency room in 2007? Available from: http://www​.cdc.gov/nchs​/data/databriefs/db38.pdf. [PubMed: 20487622]
3.
Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997–2007. JAMA. 2010;304(6):664–70. [PMC free article: PMC3123697] [PubMed: 20699458]
4.
Peppe EM, Mays JW, Chang HC, Becker E, DiJulio B. Characteristics of frequent emergency department users. Menlo Park, CA: Kaiser Family Foundation; 2007. Available from: http://www​.kff.org/insurance​/upload/7696.pdf.
5.
Cunningham PJ, May JH. Insured Americans drive surge in emergency department visits. Washington, DC: Center for Studying Health System Change; 2003. Issue Brief no. 70. Available from: http://www​.hschange.com/CONTENT/613/ [PubMed: 14577417]
6.
Kaiser Commission on Medicaid and the Uninsured. The uninsured and the difference health insurance makes. Washington, DC: Kaiser Family Foundation; 2011. Available from: http://www​.kff.org/uninsured​/upload/1420-13.pdf.
7.
Bloom B, Cohen RA. NCHS Data Brief no. 55. Hyattsville, MD: NCHS; 2011. Young adults seeking medical care: Do race and ethnicity matter? Available from: http://www​.cdc.gov/nchs​/data/databriefs/db55.pdf. [PubMed: 25056254]
8.
Government Accountability Office. Hospital emergency departments: Health center strategies that may help reduce their use. Washington, DC: GAO; 2011. Pub no. GAO-11-414R. Available from: http://www​.gao.gov/assets/100/97416.pdf.

Triage of Visits

In 2009–2010, 10% of visits by children and 8% of visits by adults aged 18–64 were classified as nonurgent.

Triage is a way for emergency departments to prioritize patients by acuity level into categories indicating how quickly they should be seen by a health provider. Triage systems can be influenced by factors other than the patient’s clinical presentation, such as the patient’s age, race, and comorbidities, and the number of patients, time of day, and available resources at the emergency department (1). Although research suggests that the majority of emergency department visits are for serious medical symptoms, Medicaid patients’ use of emergency departments for nonemergency situations is commonly cited as a cause of emergency department crowding and misuse (2).

The acuity of visits was classified into four categories: emergent (should be seen in under 15 minutes), urgent (see in 15–60 minutes), semiurgent (see in 61 minutes up to 2 hours), and nonurgent (see in 2 hours or more). In 2009–2010, among children, four-fifths of visits were classified as urgent and semiurgent, with 9% classified as emergent and 10% as nonurgent. The percentage of visits classified as emergent and urgent was similar for each primary payer category. Visits by children with Medicaid as the primary payer were more likely to be classified as semiurgent (49%) than visits by children with private insurance (44%).

In 2009–2010, four-fifths of visits by adults aged 18–64 were classified as urgent or semiurgent. Twelve percent of visits were classified as emergent, and 8% were classified as nonurgent. The percentage of visits classified as emergent was similar for visits by adults with Medicaid, private insurance, and self-pay or other as the primary payer (11%–12%).

Figure 22 is a bar chart showing triage of emergency department visits, by age group and primary payer, for 2009 and 2010 (average annual).

Figure 22Triage of emergency department visits, by age and primary payer: United States, average annual, 2009–2010

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2012.htm#fig22

NOTE: See data table for Figure 22.

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, Emergency Department Component. See Appendix I, National Hospital Ambulatory Medical Care Survey (NHAMCS).

References

1.
Schrader CD, Lewis LM. Racial disparity in emergency department triage. J Emerg Med. 2013;44(2):511–8. [PubMed: 22818646]
2.
Sommers A, Boukus ER, Carrier E. Dispelling myths about emergency department use: Majority of Medicaid visits are for urgent or more serious symptoms. Washington, DC: Center for Studying Health System Change; 2012. HSC Research Brief no. 23. Available from: http://www​.hschange.com/CONTENT/1302/ [PubMed: 22787720]

Reason for Visit

In 2009–2010, cold symptoms were the most common reason for emergency department visits by children.

The patient’s reason for visiting the emergency department provides insight into their perspective on the necessity of going to the emergency department. Patients cannot always evaluate the seriousness of their symptoms, and some may visit the emergency department for a complaint that turns out to be nonurgent. Because some symptoms, such as pain, may vary by the severity of the underlying condition, the patient’s reason for visit (RFV) does not always match the physician’s diagnosis.

Patients’ RFVs are varied, but related reasons can be combined into categories. For example, “cold symptoms” is a collection of individual RFVs, including chills, fever, cough, congestion, sneezing, and sore throat. If RFVs are not combined, the most common RFV is fever for children and chest or abdominal pain for adults. See the data table for Figure 23 for more information.

Among children, more than one-quarter of all emergency department visits in 2009–2010 were for cold symptoms. Injury was the second most common RFV, accounting for more than one-fifth of visits. Other top RFVs (although less common at 5% or less) were nausea and vomiting, skin symptoms, and abdominal pain. After including the top 10 categories, there remained almost one-quarter of visits in the “all other” category.

Among adults, 14% of all emergency department visits in 2009–2010 were for injuries. Other common RFVs were abdominal pain (9%), chest pain (7%), back and neck problems (6%), and cold symptoms (6%). After accounting for the top RFVs, more than one-third of adult visits fell into the “all other” category, reflecting the variety of reasons people go to the emergency department.

Figure 23 consists of two pie charts, one for children under age 18 and one for adults aged 18 and over, showing patient’s primary reason for emergency department visit, for 2009 and 2010 (average annual).

Figure 23Patient’s primary reason for emergency department visit, by age and reason: United States, average annual, 2009–2010

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2012.htm#fig23

NOTE: See data table for Figure 23.

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, Emergency Department Component. See Appendix I, National Hospital Ambulatory Medical Care Survey (NHAMCS).

Injury

In 2008–2010, falls were the most common cause of injuries diagnosed during emergency department visits.

Injuries cost society directly in medical costs and indirectly in lost productivity (1,2). The majority of ambulatory care visits for nonfatal injuries occur in physician offices, but injuries resulting in an emergency department visit are often more serious (3). In 2010, 23% of emergency department visits—almost 30 million visits—had injury as the primary diagnosis (4).

Diagnosed injuries are classified by mechanism—the cause of the injury. The five most common mechanisms of diagnosed injury for people who sought treatment in emergency departments were falls, being struck by a person or object, motor vehicle traffic accidents (MVTs), cut, and exposure and other natural or environmental injuries.

In 2008–2010, falls, being struck by a person or object, and MVT injuries were the primary mechanisms for 14% of all emergency department visits (see data table for Figure 24). Among children, 10% of emergency department visits were due to falls, the most common injury mechanism. Being struck by a person or object (6%) was the second leading mechanism of injury for children. Among children, visits for injuries from falls, being struck, or cut were more common for boys than for girls.

Among working-age adults aged 18–64, 6% of all emergency department visits were due to falls, 3% to being struck, and 4% to MVT injuries (see data table for Figure 24). There was no difference in the percentage of visits from falls for men and women. However, the percentage of visits by men for injuries due to being struck or cut was double the percentage for women, and MVT injury visits were 26% higher among men than women.

Among persons aged 65 and over, falls were the most common cause of injuries, accounting for 13% of all emergency department visits in 2008–2010. The percentage of emergency department visits for falls was 50% higher for women (16%) than for men (10%). The other types of injury each accounted for 2% or fewer emergency department visits.

Figure 24 is a bar chart showing diagnosed injury-related emergency department visits, by sex and mechanism of injury, and by age group, for 2008, 2009, and 2010 (average annual).

Figure 24Diagnosed injury-related emergency department visits, by age, sex, and mechanism of injury: United States, average annual, 2008–2010

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2012.htm#fig24

* Estimate is considered unreliable. Relative standard error is 20%–30%.

NOTE: See data table for Figure 24.

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, Emergency Department Component. See Appendix I, National Hospital Ambulatory Medical Care Survey (NHAMCS).

References

1.
CDC. Medical expenditures attributable to injuries—United States, 2000. MMWR. 2004. pp. 1–4. Available from: http://www​.cdc.gov/mmwr​/preview/mmwrhtml/mm5301a1.htm. [PubMed: 14724557]
2.
Bergen G, Chen LH, Warner M, Fingerhut LA. Injury in the United States: 2007 Chartbook. Hyattsville, MD: NCHS; 2008. Available from: http://www​.cdc.gov/nchs​/data/misc/injury2007.pdf.
3.
Burt CW, Fingerhut LA. Injury visits to hospital emergency departments: United States, 1992–95. NCHS. Vital Health Stat. 1998. Available from: http://www​.cdc.gov/nchs​/data/series/sr_13/sr13_131.pdf. [PubMed: 9604689]
4.
CDC/NCHS. National Hospital Ambulatory Medical Care Survey. [unpublished analysis]. For more information, visit: http://www​.cdc.gov/nchs/ahcd.htm.

Wait Time to See a Physician

In 2008–2010, the mean wait time to see an emergency department physician was 55 minutes, up from 45 minutes in 1998–2000.

Long wait times to see an emergency department physician may reduce quality of care, patient satisfaction, and clinical outcomes (17). Wait times can be influenced by a variety of factors, such as hospital location, available emergency department staff, and other resources, as well as the number and nature of the patients waiting to be seen (79).

Wait times to see a physician varied by patient and hospital characteristics. In 2008–2010, mean wait times were higher for adults aged 18–64 (58 minutes) than for children (51 minutes) and for adults aged 65 and over (48 minutes). Wait times were higher for visits by females (57 minutes), compared with males (53 minutes). Wait times were highest for visits by non-Hispanic black patients (68 minutes), compared with visits by Hispanic patients (60 minutes) and non-Hispanic white patients (50 minutes).

Wait times varied by the urbanization level of the hospital location. Wait times were longest at hospitals in large metropolitan central counties (67 minutes), compared with medium and small metropolitan counties (56 minutes) and large metropolitan fringe counties (52 minutes). Mean wait times were lowest in nonmetropolitan counties, at 44 minutes for micropolitan counties and 33 minutes in the most rural counties.

Because a small proportion of visits had long wait times, the mean wait time is higher than the median; the overall mean wait time was 55 minutes in 2008–2010, compared with a median of 31 minutes (see data table for Figure 25).

Figure 25 is a bar chart showing the mean wait time to see a physician in an emergency department, by selected characteristics, for 2008, 2009, and 2010 (average annual).

Figure 25Mean wait time to see a physician in an emergency department, by selected characteristics: United States, average annual, 2008–2010

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2012.htm#fig25

NOTE: See data table for Figure 25.

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, Emergency Department Component. See Appendix I, National Hospital Ambulatory Medical Care Survey (NHAMCS).

References

1.
Institute of Medicine. Hospital-based emergency care: At the breaking point. Washington, DC: National Academies Press; 2007. Available from: http://www​.nap.edu/openbook​.php?record_id​=11621&page=1.
2.
DeLia D, Cantor J. Emergency department utilization and capacity. Princeton, NJ: Robert Wood Johnson Foundation, The Synthesis Project; 2009. Research Synthesis Report no. 17. Available from: http://www​.rwjf.org/content​/dam/farm/reports​/reports/2009/rwjf43565.
3.
Government Accountability Office. Hospital emergency departments: Crowding continues to occur, and some patients wait longer than recommended time frames. sWashington, DC: GAO; 2009. Pub no. GAO-09-347. Available from: http://www​.gao.gov/new.items/d09347.pdf.
4.
Burt CW, McCaig LF. Advance data from vital and health statistics, no 376. Hyattsville, MD: NCHS; 2006. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003–04. Available from: http://www​.cdc.gov/nchs/data/ad/ad376​.pdf. [PubMed: 17037024]
5.
ACEP Boarding Task Force. Emergency department crowding: High-impact solutions. Irving, TX: American College of Emergency Physicians; 2008. Available from: http://www​.acep.org/workarea​/DownloadAsset.aspx?id=50026.
6.
Cardoso LT, Grion CM, Matsuo T, Anami EH, Kauss IA, Seko L, Bonametti AM. Impact of delayed admission to intensive care units on mortality of critically ill patients: A cohort study. Crit Care. 2011;15(1):1–8. [PMC free article: PMC3222064] [PubMed: 21244671]
7.
Hsia RY, Tabas JA. Emergency care: The increasing weight of increasing waits. Arch Intern Med. 2009;169(20):1836–8. [PubMed: 19901134]
8.
Hing E, Bhuiya F. NCHS Data Brief no. 102. Hyattsville, MD: NCHS; 2012. Wait time for treatment in hospital emergency departments: 2009. Available from: http://www​.cdc.gov/nchs​/data/databriefs/db102.pdf. [PubMed: 23101886]
9.
Sonnenfeld N, Pitts SR, Schappert SM, Decker SL. Emergency department volume and racial and ethnic differences in waiting time in the United States. Med Care. 2012;50(4):335–41. [PubMed: 22270097]

Imaging

Between 2000 and 2010, the use of x-rays during emergency department visits was stable at 35%, while the use of advanced imaging tripled from 5% to 17%.

Diagnostic imaging techniques include x-rays (radiographs), computed tomography (CT) scans, and magnetic resonance imaging (MRI). Imaging helps narrow the potential causes of an injury or illness and aids accurate diagnosis. X-rays are the most commonly used diagnostic imaging technique. The advanced imaging technologies, such as CT and MRI, are more sophisticated tools for diagnosing and monitoring the status of a wide array of medical conditions but are more expensive than the traditional x-ray (1,2). The availability and use of advanced imaging technologies has increased substantially since their introduction in the early 1980s (1,3). Concerns have been raised about the increase in expenditures for advanced imaging scans without clear evidence that the use of advanced imaging techniques improves outcomes (1,2).

In 2010, 35% of emergency department visits included an x-ray. The use of x-rays increased with age, from 27% of visits by children, to 33% of visits by working-age adults, to 55% of visits by adults aged 65 and over. In the same year, 17% of all emergency department visits included the use of advanced imaging techniques. The use of advanced imaging also increased with age, from 6% of visits by children, to 18% of visits by working-age adults, to 29% of visits by adults aged 65 and over.

In the past decade, the percentage of emergency department visits that included an x-ray has been stable. The use of advanced imaging between 2000 and 2010 increased 3.1 times, from 5% to 17%. Although use of advanced imaging grew for all age groups from 2000 to 2010, the rise was larger among adults aged 18–64 (3.6 times higher) and those aged 65 and over (2.5 times higher).

Figure 26 is a bar chart showing emergency department visits with x-rays or advanced imaging scans ordered or provided during the visit, by age group, for 2000 and 2010.

Figure 26Emergency department visits with x-rays or advanced imaging scans ordered or provided during the visit, by age: United States, 2000 and 2010

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2012.htm#fig26

NOTES: CT is computed tomography; MRI is magnetic resonance imaging. See data table for Figure 26.

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, Emergency Department Component. See Appendix I, National Hospital Ambulatory Medical Care Survey (NHAMCS).

References

1.
Iglehart JK. The new era of medical imaging—Progress and pitfalls. N Engl J Med. 2006;354(26):2822–8. [PubMed: 16807422]
2.
Iglehart JK. Health insurers and medical-imaging policy—A work in progress. N Engl J Med. 2009;360(10):1030–7. [PubMed: 19264694]
3.
Baker LC, Atlas SW, Afendulis CC. Expanded use of imaging technology and the challenge of measuring value. Health Aff (Millwood). 2008;27(6):1467–78. [PubMed: 18997202]

Discharge Status of Emergency Department Visits

In 2009–2010, 81% of emergency department visits were discharged for follow-up care as needed, 16% ended with the patient being admitted to the hospital, 2% ended with the patient leaving without completing the visit, and less than 1% ended in the patient’s death.

Discharge status is one of the most important decisions made during the emergency department visit (1). If a life-threatening condition is missed and the patient is discharged home, there may be a repeat visit to the emergency department or a poor outcome. On the other hand, unneeded hospital admissions may lead to misuse of services (2).

Emergency department visits end in one of four ways: the patient dies in or upon arrival at the emergency department, is admitted or transferred to a hospital, is released and advised to seek follow-up care as needed, or leaves without completing the emergency department visit. The most common discharge disposition is for follow-up or additional care as needed. The second most common discharge disposition is admitted or transferred to a hospital. Fewer than 1% of emergency department visits result in death.

Emergency department visits resulting in hospital admission increased with age. In 2009–2010, 5% of visits by children resulted in an admission, compared with 42% of visits by those aged 65 or older. The percentage of visits discharged for follow-up as needed was higher for children (92%) and working-age adults (87% for those aged 18–44 and 75% for those aged 45–64) than for older adults (57%).

Figure 27 is a bar chart showing discharge status of emergency department visits, by age group, for 2009 and 2010 (average annual).

Figure 27Discharge status of emergency department visits, by age: United States, average annual, 2009–2010

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2012.htm#fig27

NOTES: A small percentage of visits result in death. See data table for Figure 27.

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, Emergency Department Component. See Appendix I, National Hospital Ambulatory Medical Care Survey (NHAMCS)

References

1.
Calder LA, Forster AJ, Stiell IG, Carr LK, Perry JJ, Vaillancourt C, Brehaut J. Mapping out the emergency department disposition decision for high-acuity patients. Ann Emerg Med. 2012;60(5):567–76. [PubMed: 22699018]
2.
Hospital-based emergency care: At the breaking point. Washington, DC: National Academies Press; 2007. Available from: http://www​.nap.edu/openbook​.php?record_id​=11621&page=1.

Drugs Prescribed at Discharge From the Emergency Department

In 2009–2010, 59% of emergency department visits (excluding hospital admissions) included at least one drug prescribed at discharge.

Drugs play an important role in emergency department care, both in treating the patient while in the emergency department and when the patient is sent home with the needed prescriptions to continue appropriate treatment. Drugs used in the emergency department may be for the immediate stabilization of the patient and require physician oversight, and therefore often differ from those prescribed at discharge. In 2009–2010, 59% of emergency department visits (excluding hospital admissions) included at least one drug prescribed at discharge. In 2009–2010, visits by those aged 18–64 were more likely to include drugs at discharge (62%), compared with visits by children (54%) and older adults aged 65 and over (47%). These percentages would likely differ for emergency department visits that result in hospital admission, due to differences in the patient’s condition and severity. This distinction is especially important when considering visits by older adults because 42% of their emergency department visits resulted in a hospital admission (Figure 27).

Across all medical care settings, the appropriate use of two of the most commonly-used classes of drugs (narcotics and antibiotics) is of concern. Narcotics play an important role in appropriate pain management, and some studies conclude that narcotic analgesics are underused for pain control in emergency departments (1). However, emergency department physicians must balance pain management against drug-seeking behavior by patients with abuse issues, all within the context of a fast-paced, transient interaction in the emergency department (13). In 2009–2010, narcotic analgesics were prescribed at discharge for 5% of visits by children, 25% by those aged 18–64, and 15% by those aged 65 and over.

Antibiotics are a mainstay of treating bacterial infections, but unnecessary antibiotic use is ineffective and costly and may contribute to future bacterial resistance (4). In 2009– 2010, 21% of visits by children, 19% by adults aged 18–64, and 16% by adults aged 65 and over had an antibiotic prescribed at discharge.

Figure 28 is a bar chart showing drugs prescribed at discharge from the emergency department, by selected drug class and age group (excluding visits resulting in inpatient admission), for 2009 and 2010 (average annual).

Figure 28Drugs prescribed at discharge from the emergency department, by selected drug class and age (excluding visits resulting in inpatient admission): United States, average annual, 2009–2010

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2012.htm#fig28

NOTE: See data table for Figure 28.

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, Emergency Department Component. See Appendix I, National Hospital Ambulatory Medical Care Survey (NHAMCS).

Reference

1.
Rupp T, Delaney KA. Inadequate analgesia in emergency medicine. Ann Emerg Med. 2004;43(4):494–503. [PubMed: 15039693]
2.
Grover CA, Close RJ, Wiele ED, Villarreal K, Goldman LM. Quantifying drug-seeking behavior: A case control study. J Emerg Med. 2012;42(1):15–21. [PubMed: 21958455]
3.
Fosnocht DE, Swanson ER, Bossart P. Patient expectations for pain medication delivery. Am J Emerg Med. 2001;19(5):399–402. [PubMed: 11555797]
4.
Ackerman S, Gonzales R. The context of antibiotic overuse. Ann Intern Med. 2012;157(3):211–2. [PubMed: 22868840]

Expenses per Emergency Department Visit

In the past decade, the mean expenditure (in 2010 dollars) for an emergency department visit that did not result in a hospital admission increased 77%, from $546 in 2000 to $969 in 2010.

Emergency care represents about 4% of all health care spending in the United States (1). On average, expenses for emergency department visits are higher than for visits to physician offices or other outpatient settings (2).

Estimates of emergency department visit expenses presented here include both hospital facility and physician charges and are limited to visits that did not result in a hospital admission. Emergency department visits that result in hospital admission are different from other emergency department visits because they are likely to involve more severe conditions, and the expenses for these visits are often combined with inpatient expenses. Data for 2000 are adjusted to 2010 dollars for comparison. Because a small proportion of visits account for a large proportion of total emergency department expenses, the mean expense is higher than the median; both mean and median expenses per visit are presented in the data table for Figure 29.

In 2010, the mean average expense for emergency department visits (where the patient was not admitted to the hospital) was $969. For children, the average was $542. Adults had higher average expenses than children, at $1,097 for working-age adults and $1,062 for older adults aged 65 and over.

Between 2000 and 2010, the mean expense for emergency department visits that did not result in a hospital admission increased 77%, from $546 (in 2010 dollars) to $969. Per-visit expenses between 2000 and 2010 were similar for visits by children. For working-age adults aged 18–64, the mean expense more than doubled, from $539 in 2000 to $1,097 in 2010. For older adults, the mean expense per visit increased by almost 50%, from $720 to $1,062.

Figure 29 is a bar chart showing emergency department expenditures, mean dollars per visit, by age group (excluding visits resulting in inpatient admission), for 2000 and 2010.

Figure 29Emergency department expenditures, mean dollars per visit, by age (excluding visits resulting in inpatient admission): United States, 2000 and 2010

Excel and PowerPoint: http://www.cdc.gov/nchs/hus/contents2012.htm#fig29

NOTES: Expenditure data for 2000 were adjusted to 2010 dollars by the gross domestic product (GDP) implicit price deflator. See data table for Figure 29.

SOURCE: Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost Trends, Medical Expenditure Panel Survey. See Appendix I, Medical Expenditure Panel Survey (MEPS).

References

1.
Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost Trends, Medical Expenditure Panel Survey. [unpublished analysis]. For more information, visit: http://meps​.ahrq.gov/mepsweb/
2.
Machlin S, Chowdhury S. Expenses and characteristics of physician visits in different ambulatory care settings, 2008. Rockville, MD: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey; 2011. Statistical Brief no. 318. Available from: http://meps​.ahrq.gov​/mepsweb/data_files/publications​/st318/stat318.pdf.

Data Tables for Special Feature: Figures 20–29

Data table for Figure 20. Emergency department visits in the past 12 months, by age: United States, 2001–2011

Data table for Figure 21. One or more emergency department visits in the past 12 months, by age and type of coverage: United States, 2001–2011

Data table for Figure 22. Triage of emergency department visits, by age and primary payer: United States, average annual, 2009–2010

Data table for Figure 23. Patient’s primary reason for emergency department visit, by age and reason: United States, average annual, 2009–2010

Data table for Figure 24. Diagnosed injury-related emergency department visits, by age, sex, and mechanism of injury: United States, average annual, 2008–2010

Data table for Figure 25. Wait time to see a physician in an emergency department, by selected characteristics: United States, average annual, 1998–2000 and 2008–2010

Data table for Figure 26. Emergency department visits with x-rays or advanced imaging scans ordered or provided during the visit, by age: United States, 2000 and 2010

Data table for Figure 27. Discharge status of emergency department visits, by age: United States, average annual, 1999–2000 and 2009–2010

Data table for Figure 28. Drugs prescribed at discharge from the emergency department, by selected drug class and age (excluding visits resulting in inpatient admission): United States, average annual, 2009–2010

Data table for Figure 29. Emergency department expenditures, dollars per visit, by age (excluding visits resulting in inpatient admission): United States, 2000 and 2010

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