Prior Outpatient Care Use in Emergency Department Patients with Low- and High-acuity Conditions in Germany

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INTRODUCTION: The key role of emergency departments (ED) is to treat severe and life-threatening cases. A rise in ED visits, particularly for low-acuity conditions, places a burden on resources which may hinder efficient care for high-acuity conditions. We investigated the association between previous outpatient healthcare services use and low-acuity visits in EDs in Germany. METHODS: We analyzed data from the Initiative for Emergency Department Evaluation and Data Collection project, with 454,747 ED visits by 353,926 patients collected from 16 EDs in Germany in 2016. We included a subset of 228,753 (64.6%) patients with 299,914 (66.0%) visits from 12 of the participating EDs for which outpatient care data was available. We categorized ED presentations into low- or high-acuity based on transportation to the ED, triage category, hospital admission status, and intrahospital mortality. By merging patient hospital records with outpatient billing information, we assessed outpatient care utilization prior to ED visits. Using a generalized mixed-effects model, we investigated the relationship between acuity level and outpatient care utilization, adjusting for age, sex, and type of residential area. RESULTS: Low-acuity patients were considerably younger than high-acuity (mean age ± standard deviation: 45 ±19 vs 58 ±21 years) and used outpatient services less often within 10 days prior to their ED visit: 40.6% vs 49.5%. Key associations for low-acuity ED visits included younger age (per 10-year categories: adjusted odds ratios 0.72, 95% confidence interval 0.72-0.73), urban residence (1.17; 1.13-1.22), and timing of the last outpatient contact. Longer durations since the last outpatient contact were associated with a higher likelihood of presenting to the ED with low-acuity symptoms. Compared to patients who visited their primary care physician (PCP) shortly before their ED visit, those with PCP contact 1-6 months (1.22; 1.19-1.25) and over six months prior (1.33; 1.26-1.41) were more likely to present with low-acuity conditions. CONCLUSION: While almost half of both low- and high-acuity patient groups utilized outpatient services prior to the ED visit, low-acuity patients were generally younger and had fewer such contacts. The majority had accessed both primary care and the ED, challenging the assumption that low-acuity patients routinely bypass outpatient care before seeking emergency services. This raises the question of what limitations or unaddressed needs in outpatient care drive these patients to seek subsequent care in the ED. More research is needed to explore the structural and systemic factors influencing low-acuity ED visits.

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