Beyond Imaging and Laboratory Testing: Predictors of Emergency Department Return Visits in Patients With Nonstructural Abdominal Pain

Recurrent abdominal pain without identifiable structural pathology is a common reason for emergency department (ED) visits and return utilization. While clinical guidelines such as GRACE-3 emphasize judicious diagnostic testing in low-risk patients, factors associated with ED return visits remain poorly understood. We sought to identify demographic, clinical, psychosocial, substance use, and patient-reported factors associated with 12-month ED return visits among patients presenting with recurrent abdominal pain and no identified structural cause.

We conducted a multicenter observational study of adult ED patients presenting with recurrent abdominal pain and no structural diagnosis requiring procedural or surgical intervention. Data were collected across three academic health systems and included demographic characteristics, clinical features, ED management, substance use risk, social determinants of health, and standardized patient-reported outcomes (PROMIS). The primary outcome was ≥1 ED return visit within 12 months of the index encounter. Penalized regression (LASSO) was used for variable selection, followed by multivariable logistic regression adjusting for demographic characteristics and study site.

Among 162 included patients, 55 (34.0%) had at least one ED return visit within 12 months. Patients with ED return visits had higher index pain scores, more frequent prior abdominal imaging, and were more likely to receive opioid analgesics during the index ED encounter. Psychosocial and behavioral factors were more common among patients with ED return visits, including adverse social determinants of health (SDH), substance use risk, and worse patient-reported fatigue, sleep disturbance, pain interference and social participation. In adjusted analyses, variables retained in the final multivariable model included measures of pain severity, adverse SDH, substance use risk, and patient-reported health status.

ED return visits within 12 months were common and were associated with psychosocial, behavioral, and functional factors rather than markers of acute disease severity. These findings complement GRACE-3–informed recommendations for diagnostic restraint and suggest that patient-centered and social factors play a central role in recurrent ED utilization. This study provides foundational data to inform future testing and study.