ED care appears to have become more intense, according to an analysis of 35,490 visits in 2007 and 19,467 visits in 2016.1

“The motivation for the paper is to describe what we as ED clinicians have felt to some degree, which is that emergency care has greatly increased in intensity over the years,” says Shih-Chuan (Andrew) Chou, MD, MPH, SM, one of the study’s authors and an instructor at Harvard.

Chou and colleagues observed a decline in low-severity illnesses and fewer privately insured and uninsured patients. Concurrently, they found a substantial increase in the proportion of Medicaid patients, more advanced imaging and blood tests, and more patients receiving four or more medications. “Patients are older, have more comorbidities, and generally require more care, including medications, diagnostic testing, and procedures,” says Chou, attending physician in the department of emergency medicine at Brigham and Women’s Hospital in Boston.

Both the patients and the care they require are more complex. “EPs are, in some ways, taking on a higher overall risk of patients suffering from adverse events,” Chou says.

On the other hand, previous research has shown improved mortality over time for ED patients, whether they were admitted or discharged.2

“Whether the risks from having an increasingly complex patient population are truly mitigated by more intense use of advanced imaging or other costly studies often associated with defensive medicine remains unclear,” Chou reports.

Another group of investigators studied whether advanced imaging use during ED visits is linked to fewer ED visits resulting in hospital stays.3 “Hospitalization rates among ED visits have been declining. There has been speculation that it is because we are providing more intensive care in the ED, and thus allowing patients to be discharged,” says Chou, who served as lead author on this study.

The authors wanted to know if ED patients undergoing CT/MRIs experienced a larger decrease in admission rates than those who did not receive imaging. Researchers analyzed data from the National Hospital Ambulatory Medical Care Survey to examine changes in ED hospitalization rates from 2007-2008 and 2015-2016, and compared ED visits with or without advanced imaging (CT, MRI, and ultrasound).

Admission rates for ED visits with and without advanced imaging were not significantly different. “Overall, advanced imaging seemed to have fairly little impact on the trend of decreasing ED-to-hospital admissions,” Chou observes.

Patients age 65 or older, non-Hispanic whites, women, and patients with Medicare were more likely to receive advanced imaging. “Perceived litigation risk has been often cited as one of the top reasons for ordering low-value imaging in many settings, including the ED,” Chou notes.

Higher costs and more radiation exposure (and hospitalizations) probably could have been avoided in many cases. Yet EPs know it is possible they will be sued for failing to order a diagnostic test. That is an important consideration for future medical malpractice reforms. “Clinicians should not be penalized for making reasonable recommendations against obtaining tests that often are not indicated, and patients ended up with an unexpected outcome,” Chou says.


  1. Chou SC, Baker O, Schuur JD. Changes in emergency department care intensity from 2007-16: Analysis of the National Hospital Ambulatory Medical Care Survey. West J Emerg Med 2020;21:209-216.
  2. Burke LG, Epstein SK, Burke RC, et al. Trends in mortality for Medicare beneficiaries treated in the emergency department from 2009 to 2016. JAMA Intern Med 2019;180:1-9
  3. Chou SC, Nagurney JM, Schuur JD, et al. Advanced imaging and trends in hospitalizations from the emergency department. PLoS One 2020;15:e0239059.