• admission avoidance
• hospitalisations
• cost effectiveness

The evidence seems clear: we spend so much on healthcare, and get so little in return. Despite wide variation in the amount we spend on care, patients’ outcomes are often the same.1 So clearly, we should just do less. Indeed, given the growing problems of overdiagnosis and overtreatment, less is more.

As emergency physicians, we deliver a fair amount of high-intensity care. Yes, good care can sometimes be as simple as an astute diagnosis or a kind word. But it can also involve cross-sectional imaging, invasive procedures and hospital admission. At the right time and for the right patient, we believe, this care can be the difference between life and death.

And yet this care is coming under increasing scrutiny from payers and policy makers.

While emergency care accounts for a small fraction of direct health system costs,2 the decision to admit a patient to the hospital is an expensive one indeed. There are many good reasons to send patients home—reducing crowding, avoiding hospital-acquired infections and more. But the driving force behind efforts to reduce admissions today is simple: to reduce costs. As a result, physicians everywhere face increasing pressure to discharge patients to home.

This poses a particular dilemma for emergency physicians. On one hand, the rest of the world seems very certain we should be sending more patients home. On the other, our experience suggests that failures of risk stratification and mistriage to home can have terrible consequences.