gms | German Medical Science

Background: Internationally, emergency departments (ED) are treating increasing numbers of patients with conditions that could have been managed appropriately in ambulatory care (AC) settings. The aim of our study was to develop the first consensus-based list of AC-sensitive conditions commonly seen in German EDs, and explore predictors of these visits.

Research question: Based on group consensus methods, our first aim was to develop an instrument to systemise the identification of ED cases amenable to treatment with AC. These cases include patients treated on the same day in hospital EDs but exclude emergency admissions. Additionally, we identified potential reasons why patients seek EDs rather than AC. The second aim was to describe characteristics of patients visiting EDs with AC-sensitive conditions based on German data from 2015. The third aim was to investigate the relationship between patient characteristics, AC settings, and the rate of AC-sensitive ED cases using linear spatial models at the level of German districts.

Methods: Our study used a Delphi survey of 30 physicians to compile a list of conditions they agreed were amenable to AC treatment. The group identified reasons why patients visit EDs instead of AC. We used the results to inform spatial regression models analysing the association of patient characteristics and attributes of AC with AC-sensitive ED visits based on 2015 district-level data.

Results: Our study provides a list of AC-sensitive conditions based on the German ED context. Results suggest that, up to the age of 70, the older the patients, the less likely they seek EDs for these conditions. Results of our regression analyses suggest that AC-sensitive ED rates were significantly higher in districts with lower physician density. Patients’ urgency perception and preferences were identified as main drivers of AC-sensitive ED visits.

Conclusion: A list of AC-sensitive ED conditions can be used as a monitoring instrument and for further analyses of routine data to inform policy makers seeking to improve resource use and allocation.

Discussion: The list can be used to compute the rate of AC-sensitive ED visits among regions in Germany, and potentially in other countries, in order to monitor use of EDs and access to AC. One important strength of the compiled list is that it can be computed using data collected routinely. Results are therefore easy to compile, comparable among regions and hospitals and not biased by self-reported urgency. Using a structured, consensus-based process that drew upon the expert opinion of a panel of physicians, we account in our list for the fact that not all of these conditions are fully preventable through AC treatment. Incorporating this fact, our results compare well with national and international studies which estimate that between 20% and 43% of such cases are treatable by ambulatory care.

Practical implications: Future policy measures should aim to help better guide patients through the healthcare system so that they receive the best care in the place that is most appropriate, both in terms of quality, safety and continuity of care and with regard to efficient resource use and allocation.