Inappropriate ED visits: patient responsibility or an attribution bias?

Abstract

The study by Naouri et al in this issue of BMJ Quality and Safety describes an ambitious, 24-hour cross-sectional physician survey and chart review of all the emergency departments (ED) in France to characterise the ‘inappropriateness’ of ED visits.1 The determination of inappropriateness for any given visit was based on (A) physician opinion, (B) physician determination of ambulatory care sensitivity, or (C) resource utilisation. Based on these measures, the authors concluded that between 13% and 27% of ED visits were inappropriate. Further, patients with supplemental public insurance (a proxy for the socioeconomic disadvantaged in France) were 15%–33% more likely to use the ED inappropriately. Naouri’s study is part of a growing body of literature that characterises ED use as inappropriate, avoidable, ambulatory care sensitive or preventable.2 3 While there is precedent and potential merit in classifying healthcare services based on their value,4 this trend raises some concerns—as the authors rightly conclude—when describing the use of EDs by disadvantaged populations. Determining the patient’s ED visit as inappropriate, without consideration of broader contextual factors, is an example of attribution bias: the tendency for people to overemphasise individual and personality-based explanations for behaviours while underemphasising situational explanations.5 We may blame patients for visiting the ED inappropriately, when in reality, healthcare systems are often designed to funnel patients towards …