Performance Measurement in the Hospital Outpatient Setting. Common Reasons for Visits in the Hospital Outpatient Setting and Emergency Department


Figures 3.1 and 3.2 and Table 3.1 highlight the common reasons for E&M visits to the HOPS and ED. The clinical categories in Figures 3.1 and 3.2 represent 100 percent of the primary diagnoses associated with visits to the HOPS and ED, respectively, and are organized alphabetically. Table 3.1 provides additional information for the clinical categories that represent at least five percent of either HOPS or ED visits. Within these clinical categories, Table 3.1 presents more detailed diagnostic groups that account for at least 0.5 percent or more of the total diagnoses. The diagnostic groups are listed in order of the HOPS percentage of total diagnoses. Therefore, the sum of the percentages for diagnostic groups within a clinical category will not equal the percentage for the category. Appendix C presents more detailed information (i.e., for all of the clinical categories).

Figure 3.1. HOPS Visits by Clinical Category, 2005

bar chart of percentages of clinical visits by category

Figure 3.2. ED Visits by Clinical Category, 2005

bar chart of clinical category visits

The analysis reveals that in 2005 the key reasons for HOPS (i.e., non-ED) hospital outpatient visits tended to be similar to the major reasons for visits in the physician office setting (see Figure 3.1 and Table 3.1). General medical conditions (35.2 percent) constitute the largest proportion of HOPS visits by Medicare patients and address common chronic conditions, such as hypertension (7.4 percent), aftercare for procedures (6.4 percent), and specific and general symptoms (e.g., fever, dizziness) for which an underlying etiology is sought (4.6 percent). Oncology and neoplasia conditions were the next most frequent reasons for visits (13.1 percent), followed by orthopedic conditions (10.4 percent), particularly diagnoses such as back pain and arthritis. Endocrinology conditions, such as diabetes, were the fourth most common clinical category, representing 7.0 percent of HOPS visits. These findings are similar to those of the 2004 National Ambulatory Medical Care Survey in which the top diagnoses in physician offices for individuals ages 65 and older were: (1) malignant neoplasm, (2) essential hypertension, (3) diabetes mellitus, (4) arthroplasties and related disorders, and (5) heart disease, excluding ischemic (Hing et al, 2006).

Our analysis also reveals that in 2005 general medical conditions (43.4 percent) were the key reasons for ED visits (see Figure 3.2 and Table 3.1). The most common reason for such visits was found to be “symptoms” (20.4 percent), generally for unanticipated acute care where patients either present with: (1) new onset of symptoms, from which a differential diagnosis is created and a plan developed to determine the etiology of the presenting findings; or (2) a new or worsening diagnosis for which acute intervention is sought. Injury, either orthopedic (e.g., back pain, sprains, fractures) or of a more general nature (e.g., laceration), constituted the next most common reason for ED encounters within the general medical category (6.15 percent). Given the nature of ED practice, patients’ reasons for seeking emergency care overlap nearly every clinical discipline.

Table 3.2. Diagnoses for Visits to the HOPS and ED by Medicare Beneficiaries, 200522
Total Encounters
Clinical Category
Diagnostic Group
Diagnostic Group
Medicine-General 35.21%     43.40%    
    Hypertension 7.42%   Symptoms 20.35%
    Aftercare, specific procedures 6.40%   Injury 6.15%
    Symptoms 4.48%   COPD and related 3.49%
    Metabolic/nutrition 2.37%   Acute respiratory infection 2.78%
    Health system encounter 2.18%   Metabolic/nutrition 1.47%
    COPD and related 1.99%   Complications 1.41%
    Venous disease 1.97%   Hypertension 1.39%
    General exam 1.49%   Infectious and parasitic disease 1.23%
    Acute respiratory infection 1.34%   Aftercare, specific procedures 1.08%
    Complications 1.04%   Venous disease 0.72%
    Arterial disease 0.83%   Poisonings 0.55%
    Upper respiratory tract 0.56%   Toxic effects-external causes 0.50%
Medicine-Oncology/Neoplasia  13.10%     0.88%    
    Cancer 9.17%   Hematology 0.58%
    Hematology 2.35%      
    Neoplasm-uncertain behavior 0.54%      
Orthopedics 10.39%     16.61%    
    Back disorders 3.92%   Back disorders 3.94%
    Arthropathies 1.95%   Sprains and strains 3.63%
    Rheumatism 1.73%   Fracture 2.75%
    Other joint disorders 1.31%   Rheumatism 2.59%
    Osteopathies, chondropathies 0.90%   Other joint disorders 2.02%
          Arthropathies 0.70%
*Totals represent all encounters associated with an E&M claim in 2005
Table 3.2. Diagnoses for Visits to the HOPS and ED by Medicare Beneficiaries, 2005 (continued)
Total Encounters
Clinical Category
Diagnostic Group
Diagnostic Group
Medicine-Endocrinology 7.03%     1.62%    
    Endocrine, metabolic 6.98%   Endocrine, metabolic 1.62%
Medicine-Cardiology  6.68%     3.45%    
    Conduction/dysrhythmias 2.48%   Conduction/dysrhythmias 1.28%
    Ischemic heart 1.82%   Heart failure 0.86%
    Heart failure 1.33%   Symptoms 0.62%
          Ischemic heart 0.60%
Dermatology 6.65%     4.21%    
    Other skin diseases 4.39%   Skin infections 1.93%
    Skin infections 0.81%   Symptoms 1.09%
    Inflammatory skin conditions 0.75%   Other skin diseases 0.63%
    Symptoms 0.60%   Inflammatory skin conditions 0.56%
Medicine-GI 2.37%     6.26%    
    Upper GI 0.62%   Symptoms 1.78%
          Upper GI 1.17%
          Functional digestive 0.93%
          Inflammatory bowel 0.84%
Urology 2.12%     5.32%    
    Symptoms 0.61%   Urinary tract infection 2.40%
    Urinary tract infection 0.53%   Symptoms 1.20%
Notes: *Totals represent all encounters associated with an E&M claim in 2005.
Table note: The percentages associated with each diagnosis within a clinical category may not sum to the percentage for the clinical category given that we only list diagnoses at 0.5 percent or higher.

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