To Which Extent are Patients Responsible for Inefficient Emergency Department Visits?

Inappropriate use of Emergency Departments (EDs) is rising in many OECD countries. In the available literature on avoidable ED visits, only a few paper use a direct measure of avoidable visits, and so far no paper was able to compare the impacts of patient and of health system characteristics on inappropriate visits. In this paper, we use a survey that recorded a direct assessment of the visit appropriateness for 15,714 patients in 439 EDs in France, with detailed information on both patient and health system characteristics. We consider a recursive two-equation model, where the first equation describes patient decision to visit ED on self-referral, and the second the appropriateness of the visit, conditional on this decision. Dealing with the endogeneity of patient decision to visit ED on self-referral, we find that 72.7% of the explained variability of appropriateness is due to patient characteristics and 27.1% to the health system organization