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The Minnesota algorithm may thus provide a useful tool for investigating ED use in Medicare beneficiaries.

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We found considerable evidence that the Billings/Ballard algorithm's diagnosis severities are inaccurate when applied to a Medicare population.

Our study sample includes 148 000 ED visits with a primary diagnosis considered 100% PCT in the original Billings study; but in our sample, 49% of these ED visits resulted in a hospital admission, received critical care in the ED or received the most severe level of ED evaluation and management code, indicating a high complexity or high severity problem unlikely to be treatable in primary care.

Those probabilities do not vary by patient characteristics like age, comorbidity, frailty or presenting problem.

Nor do they vary by social contexts like availability of primary care.

Identifying less severe ED visits is a priority for determining the most appropriate setting for medical care.

One technique for classifying ED visit severity applies an algorithm developed by Billings 7 for a list of recent research studies using the algorithm.

Research has identified important gaps between elders' needs and the environment of the ED.

Instead, we propose using the clinical judgement of the treating ED physician to determine whether a visit could have been conducted in a primary care setting.

We infer physician judgement using the procedures that were billed for the visit, with special attention to the evaluation and management code representing the complexity and severity of the visit.

Study design and setting This is a validation study using 2011–2012 Medicare claims data for a nationally representative 5% sample of fee-for-service beneficiaries to compare the new measure's performance to the Ballard variant of the Billings algorithm in predicting hospitalisation and death following an ED visit.

Results The Minnesota algorithm is a strong predictor of hospitalisations and deaths, with performance similar to or better than the most commonly used existing algorithm to assess the severity of ED visits.

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