Nationwide retrospective analysis of non-justified emergency department visits in Israel

Abstract Background: Emergency Departments (EDs) worldwide are increasingly utilized for non-urgent cases, imposing substantial clinical and economic burdens. In Israel, there is limited nationwide data evaluating the scope and predictors of non-justified ED utilization. This study aimed to evaluate the extent and associated determinants of non-justified ED visits in Israel. Methods: This retrospective nationwide study analyzed 2,843,190 ED visits that occurred between January 2018 and April 30, 2022, collected from all general hospitals operated by Clalit Health Services and one additional public hospital (Assuta Ashdod Public Hospital). Visits were classified as justified or non-justified using a validated multi-parameter classification algorithm. Multivariable logistic regression analyses were conducted to identify independent predictors. Model discrimination was assessed using receiver operating characteristic (ROC) curve analysis. Generalized Estimating Equations (GEE) models were applied to account for repeated visits. Results: Overall, 49.4% of ED visits were classified as non-justified. Younger age, female gender, self-referral, shorter visit duration, non-specific presenting complaints, and several diagnoses were significantly associated with non-justified visits. The model showed good discriminatory ability (AUC=0.79), and GEE analysis confirmed these associations remained robust across repeated visits. Conclusions: Nearly half of ED visits in Israel may be avoidable and managed in community care settings. A multifaceted approach is required, including strengthening primary care services, improving triage processes, enhancing public education, and implementing predictive models to optimize ED utilization and resource allocation.