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Access to care among emergency department patients
  1. Catherine A Marco,
  2. Mark Weiner,
  3. Sharon L Ream,
  4. Dan Lumbrezer,
  5. Djuro Karanovic
  1. University of Toledo College of Medicine, Toledo, Ohio, USA
  1. Correspondence to Dr Catherine A Marco, Mail Stop 1114, 1251 UTMC, 3045 Arlington Avenue, Toledo, OH 43614, USA; catherine.marco{at}utoledo.edu

Abstract

Objective The number of annual patient visits to US emergency departments (ED) has been increasing since 1995, whereas the number of ED is decreasing. Previous studies have identified many reasons why patients seek care in ED, including lack of access to care elsewhere, lack of insurance, inability to see their doctor in a timely manner and lower levels of social support. This study identifies factors that influence patients' decisions to seek care in ED and assesses their access to primary care.

Methods A prospective study, conducted by standardised verbal interview with adult ED patients, was performed in the XXX ED during June–July 2009. Non-English speaking patients, the mentally incapacitated and those under severe distress were excluded. Consenting patients were asked a series of questions on access to primary care, factors that influenced their decision to attend the ED, health insurance status and demographic information.

Results Among 292 study participants (89% response rate), the majority were over 40 years (52%), Caucasian (69%) and unemployed (58%). Among employed participants, 66% (N=88/133) of employers offered health insurance. Most participants had a primary care physician (PCP; 73%; N=214), but a minority had called their PCP about the current problem (31%; N=78/253). Most participants came to the ED because of convenience/location (41%) or preference for this institution (23%). Participants came to the ED, rather than their regular doctor, because they had no PCP (27%), an emergency condition (19%), or communication challenges (17%).

Conclusion Convenience, location, institutional preference and access to other physicians are common factors that influence patients' decisions to seek care in ED.

  • Cardiac care
  • care systems
  • emergency care systems
  • primary care

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In 2006, the number of patients in the USA seeking care in an emergency department (ED) reached 119 million annual visits.1–6 From 1995 to 2005, the number of annual ED visits increased 20%, whereas the number of ED decreased by 10%, resulting in a mean ED increase in volume from 23 000 to 30 000.1–6

Previous literature has identified certain factors associated with non-urgent ED visits, including hospital geographical location, transportation time, problems with their primary care physician (PCP), hours of PCP access and lack of insurance.7–10 Previous literature has demonstrated that primary care follow-up after an ED visit is associated with a lower rate of subsequent ED use.11 A recent Medline search (keywords emergency, access and repeat, 5/10/2009) identified no publications specifically addressing access to care among ED patients using a comprehensive structured interview. Insight into access to care and reasons for seeking ED treatment may provide guidance for policy development and support systems that will lead to improved medical care among the US population. This study was undertaken to assess ED patients' reasons for seeking emergency care, including access to primary medical care, health insurance, financial issues, convenience and transportation.

Methods

Study design and setting

This prospective survey was conducted at University of Toledo Medical Center, an urban university hospital with an annual volume of 34 000. The study was approved by the local institutional review board.

Participants

All consenting adult ED patients, aged 18 years and over, were eligible for study participation. Exclusion criteria included prisoners, non-English-speaking patients, mentally incapacitated patients, patients in severe distress and patients who chose not to participate.

Protocol

Following verbal consent, structured verbal interviews were conducted by trained research assistants as a convenience sample when research assistants worked, during June and July 2009. Data collected during the interviews included demographic information (age, gender, ethnicity, income, education level, insurance status), chief complaint, and questions about access to medical care and reasons for seeking emergency care (see supplementary appendix 1, available online only). No protected health information was collected. In order to obtain a balanced ED sample population, patients were interviewed during both day and night shifts including coverage of weekdays and weekends. Patients were informed that the interview was optional and would occur while waiting to avoid interfering with their treatment.

Data collection and processing

Following the structured interview, data were coded and entered into an Excel spreadsheet. Free text responses were coded categorically for open-ended questions (13, 16, 18, 19).

Outcomes measures

Main outcome measures included patient responses to standardised open-ended questions regarding access to care and relationship to ED utilisation.

Primary data analysis

Statistics are descriptive in nature without hypothesis testing. Binary data are presented as frequency (%). Count data are presented as median (mean±SD). Data were analysed using χ2 or Fisher's exact p value for parametric data, or Mann–Whitney–Wilcoxon tests for non-parametric data, in which no assumptions were made about distribution. Data analysis was performed using SAS version 9.0.

Results

A total of 328 patients was eligible for study participation and 292 (89%) consented. This represents approximately 7% of the ED volume during the study period. Table 1 details the demographics of the study population. Many patients cited previous outpatient visits for the current problem (table 2)

Table 1

Demographic information on study participants

Table 2

Number of outpatient visits for current problem

The most common reasons cited for not having a PCP were: financial constraints (32%) and looking for one currently (21%) (table 3).

Table 3

Reasons cited by participants for lack of primary care*

Most participants chose to come to the ED because of convenience/location (41%) or preference for our institution (23%). Only a minority came to the ED because of an emergency medical condition (5%) (Table 4). Among participants who chose to come to the ED, rather than call their regular doctor, the reasons cited included: no primary care provider (27%), emergency condition (19%), or communication challenges (17%) (table 5).

Table 4

Why did you choose to come to the ED today?*

Table 5

Reasons participants did not attempt to call PCP about current problem*

Self-pay patients had significantly fewer ED visits and fewer total outpatient visits in the past 6 months compared with patients with insurance (Table 6). Patients with higher incomes (≥US$40 000) had significantly more ED visits and more total outpatient visits compared with patients with incomes less than US$40 000 (Table 7).

Table 6

Differences in number of ED visits or total outpatient visits with respect to insurance type*

Table 7

Differences in number of ED visits or total outpatient visits with respect to education and income*

Discussion

Patient perspectives on emergency care are important to understand, to allow the medical community to address patient needs and the consequences of seeking emergency care. One important consequence is the commonplace problem of ED crowding. Crowding in ED has emerged as a serious issue. Both total and per capita visits have been steadily increasing for decades, while the number of ED has decreased.12 More importantly, inpatient capacity has been reduced, leading to ED boarding and stalled patient outflow.13–15 Crowding hinders the ability of medical professionals to provide adequate care to all patients, results in long patient waits and patient dissatisfaction, and has adverse effects on patient health.16 Patients who frequent the ED receive less effective chronic disease management and fewer educational opportunities aimed at preventive care, and they incur higher healthcare costs (both for the healthcare system and for the patient).17

Emergency medical conditions are clearly an important reason for seeking medical care. A previous study found that urgent patients comprise 90% of the ED population, and this study clearly defined an emergent condition as one needing to be seen within 1–14 min of ED arrival.12 However, only 5% of the patients in our study reported an emergent condition as their reason for coming to the ED. This disparity may be explained by the fact that our study relied on the patients' own assessments of their conditions, and the most critical patients were excluded from participation in this study. Other explanations may include differences in interpretations of the terms ‘urgent’ and ‘emergent’, which were interpreted by the respondents. Further understanding of this issue may be elucidated in future research to address differences in acuity in various ED settings.

The impact of health insurance on access to care is significant. We confirmed what a previous study18 found: patients with no form of health insurance have less frequent visits to the ED than patients with any form of health insurance (public or private). This study also concurred with previous studies on factors associated with frequent ED use: hospital location, convenience, and hours of PCP access.7–10 Our study differed somewhat from a recent report that found that uninsured patients do not seek ED care because of convenience.19 In many areas, the ED functions as a source of primary care for uninsured patients in the geographical area.

Several newly identified ED factors influencing seeking emergency care were evident in our patient population, including PCP referral and loyalty to our institution. There are 13 hospitals within an 8-mile radius of our institution. Twenty-four per cent of study participants contacted their PCP before visiting the ED and 14% of study participants were referred to our facility by their PCP. Patients who were visiting the ED outside of business hours often said their PCP was associated with our hospital, and that is why they came to our ED. We also found that patients feel a sense of loyalty to a certain hospital. Patients in our study frequently cited a preference for our institution over other hospitals in the same city. Although ED crowding is reported to be a result of inhibited access to other avenues of care, recent studies have found that the problem is much more complex and actually has little to do with primary care access.20 Our results support the assertion that patients choose to use the ED for a variety of other reasons, namely convenience and reputation.

Location is an important factor identified by participants for seeking emergency care. A previous study found that people who live in communities with more access to PCP have fewer ED visits, as do people who live farther from ED.7 Addressing some of these community characteristics may have a larger impact on ED overcrowding than addressing the characteristics of individual patients. These issues are, however, more difficult to address. For example, 71% of Americans live within 30 min of an ED,21 and the effects of improved access to primary care on ED visits is unknown.

Expanding access to PCP is a subject of much controversy in the medical education system.22 Medical schools are expanding their class sizes while the government is adding incentives for students to pursue careers in primary care.23 A widespread effort to expand and vary hours and add flexibility at the offices of general practitioners may have an impact in reducing ED overcrowding. However, such an attempt has been made in the past with no subsequent decrease in ED use.20 Solutions to these issues will include health reform provisions that promote patient-centered medical homes and accountable care organisations, to improve access to primary and acute care.24 The application of findings in this study, including access to PCP and reasons for seeking ED care, may provide guidance to policy and resource development to assist patient needs.

Limitations

One limitation of our study is the potential error in accuracy or interpretation of questions, due to participant self-reports rather than actual patient records. Insurance and financial information was provided by participants and not verified by study protocol. Because of the subjective nature of the study, we are unable to interpret how participants may have interpreted certain survey questions, such as ‘Why did you choose to come to the ER today?’ Many patients were unsure of how many times they had visited an ED in the previous 6 months, and they made estimates that were included in our data. We also relied on patients to report whether they had a PCP. Although we did clearly define what a PCP was, it became apparent in discussions with patients that some consider the ED physician on staff to be their PCP. Considering this, the number of patients who actually have a PCP may be lower than recorded. Because this study relied on participation interpretation of terms, such as convenience and transportation (see supplementary appendix 1, question 20, available online only), results may have been affected by variable participant interpretation of these terms. This study design relied on study participants to provide accurate and honest responses. In some cases, data may have been skewed by participants providing answers based on an expectation of the ‘correct’ answer rather than the participant's accurate report. Exclusion of patients in distress may have skewed the data. Because comparison data for all ED patients are not available, we cannot compare the study population with the ED population. However, we believe that our data are representative in light of our very high participation rate.

Conclusions

Lack of primary care, convenience, location, institutional preference and access to other physicians are common factors that influence patients' decisions to seek care in ED. Awareness of these factors influencing ED utilisation should lead to policy and resource development to address these patient needs, including transportation, access to primary care and improved communication with primary care providers. Solutions to these problems may include healthcare reform with improved access to primary care, social support including transportation, and education of healthcare providers about these issues and potential solutions.

Acknowledgments

The authors wish to thank Nancy Buderer, MS, for her statistical expertise in this research.

References

Footnotes

  • Competing interests None to declare.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the University of Toledo institutional review board.

  • Provenance and peer review Not commissioned; externally peer reviewed.