INAPPROPRIATE EMERGENCY DEPARTMENT USE - A COMPARISON OF 3 METHODOLOGIES FOR IDENTIFICATION

Objective: To determine the level of agreement between the rates of '' inappropriate'' ED visits assigned to a cohort of ambulatory patients based on three methods of defining ED use appropriateness. Methods: Am bulatory adult patients seen at one urban, university-based teaching h ospital ED between 8 AM and midnight during select days from April to June 1994 were assessed regarding the appropriateness of their ED visi ts. Patients triaged to acute resuscitation rooms in the ED were exclu ded. Eligible patients were asked to complete a 90-question survey inc luding demographics and health service use (response rate 81%), The ap propriateness of ED use was assessed for consenting respondents by 1) application of a list of 51 nonemergent complaints that have been used by managed care providers and previously published (TRIAGE), 2) use o f ten explicit criteria (e.g., need for parenteral medication) from pr ior publications (EXPLICIT), and 3) the consensus of two emergency phy sicians (EPs) reviewing the records of ED patients (PHYS). All three m ethods were applied at the time of retrospective chart review. The agr eement between methods was evaluated using kappa scores. Results: Of t he 892 eligible respondents, 64% were white, 54% were employed, 50% we re female, and 29% were uninsured. Of the respondents, 26% had no regu lar source of ambulatory care and 25% considered the ED their regular source of care. The assigned rates of ''inappropriate'' visits using t he three definitions were TRIAGE, 58%; PHYS, 47%; and EXPLICIT, 42%. O f those deemed ''inappropriate'' by the EXPLICIT criteria, 81% also we re judged as ''inappropriate'' by the TRIAGE criteria, and 72%, by the PHYS criteria. Of those patients deemed ''inappropriate'' by the TRIA GE criteria, 59% also were judged as ''inappropriate'' by the EXPLICIT criteria, and 66%, by the PHYS criteria. Levels of agreement (kappas) were TRIAGE/EXPLICIT, 0.39; TRIAGE/PHYS, 0.42; and EXPLICIT/PHYS, 0.4 2. Conclusion: There is only moderate agreement between different meth ods of determining appropriateness of ED use. Until further refinement is made in triage assessment, managed care organizations and EPs shou ld remain cautious when implementing a protocol that defines and restr icts ''inappropriate'' ED visits.