Patients Who Leave the Emergency Department Without Being Seen and Their Follow-Up Behavior: A Retrospective Descriptive Analysis

Abstract

Background

Past studies suggest that patients who leave without being seen (LWBS) by a physician from a hospital’s emergency department (ED) represent a quality and safety concern, and thus LWBS rates have often been used as an ED performance metric. There are few recent studies, however, that have examined the characteristics of the LWBS population at hospitals in the United States.

Objective

This study describes the LWBS population at a multi-hospital academic health system.

Methods

This was a retrospective study of electronic medical record data from EDs at two academic hospitals with a shared patient population that analyzed all LWBS visits during the 45-month period between July 2012 and March 2016. Demographic and clinical variables, including patient characteristics, chief complaint, acuity, and evidence of ongoing medical care, were assessed.

Results

During the study period, 2.4% of patients presenting to the study EDs left without being seen. This population tended to have lower-acuity chief complaints and nearly triple the number of ED visits as the general ED patient; 7.8% sought follow-up care from outpatient clinics and 24.8% returned to the ED within 7 days. Of this latter group, 11.5% were subsequently admitted for inpatient care, representing 0.068% of the total ED census during the study period.

Conclusions

LWBS patients are high ED utilizers who may be effectively targeted by “hotspotting.” Our 11.5% admission rate at return after LWBS compares favorably with the overall 20.9% admission rate at the study EDs and represents a small minority of all LWBS visits. Given the paucity of return ED visits after interval clinic encounters, our data suggest that patients who were seen in clinic had their medical complaint adequately resolved on a non-emergent outpatient basis, and that increased LWBS rates may reflect poor access to timely clinic-based care rather than intrinsic systemic issues within the ED.

Introduction

Patients presenting to a hospital’s emergency department (ED) who are triaged but leave without being seen (LWBS) by a physician are a major concern for health care providers and hospitals. The LWBS population, ranging from <1% of all triaged patients at some EDs to >10% at others, have been suggested in the literature to represent a shortfall in health care access, as these patients do not receive the care they originally sought 1, 2, 3, 4, 5, 6. Some studies suggest that LWBS rates may also reflect patient safety issues, as some patients who did not receive medical care when originally sought, consequently experienced avoidable outcomes (7). Conversely, it may also be hypothesized that the decision to LWBS reflects a lower-acuity complaint that has resolved or will resolve without medical intervention.

In response to the published literature, however, multiple organizations, including the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission currently use or plan to use LWBS rate as a key ED quality indicator, with potential to be used in future pay-for-quality initiatives 1, 8, 9, 10. The CMS Hospital Outpatient Quality Reporting Program (HOQRP), mandated by the Tax Relief and Health Care Act of 2006, adopted key measure “OP-22: Left Without Being Seen” in 2011 per the recommendations of the National Quality Forum’s National Voluntary Consensus Standards for Emergency Care 11, 12. CMS has since tied the reporting of LWBS rates to Medicare reimbursement, via a 2% reimbursement rate reduction if reporting requirements for OP-22 and other key measures are not met. This value, reported without contextual information on hospitals’ patient populations, is compared with that of other hospitals across the nation. As of 2018, the mean nationwide hospital LWBS rate in the HOQRP data set is 2% (13).

Despite the attention placed on LWBS rates as an ED metric, however, there are few recent studies on the demographic and clinical characteristics of the LWBS population at hospitals in the United States. In addition, few studies have examined either the subset of patients with multiple LWBS ED visits or the follow-up behavior and outcome of those patients who leave prior to seeing a physician, and thus there exist few data describing the incidence of adverse outcomes after LWBS.

The purpose of this study, therefore, was to describe the LWBS population and its subsequent follow-up encounters at a multicenter academic health system, as a first step in determining whether the population constitutes a major safety, quality, and access shortfall, and in suggesting systemic changes if indicated.