Article

Uninsured adults presenting to US emergency departments - Assumptions vs data

Robert Wood Johnson Clinical Scholars Program, University of Michigan School of Medicine, 1150 W Medical Center Dr, 6312 Medical Science Bldg 1, Ann Arbor, MI 48109-5604, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 10/2008; 300(16):1914-24. DOI: 10.1001/jama.300.16.1914
Source: PubMed

ABSTRACT Emergency departments (EDs) are experiencing increased patient volumes and serve as a source of care of last resort for uninsured patients. Common assumptions about the effect of uninsured patients on the ED often drive policy solutions.
To compare common unsupported statements about uninsured patients presenting to the ED with the best available evidence on the topic.
OVID search of MEDLINE and MEDLINE in-process citations from 1950 through September 19, 2008, using the terms (Emergency Medical Services OR Emergency Service, Hospital OR emergency department.mp OR emergency medicine.mp OR Emergency Medicine) AND (uninsured.mp OR medically uninsured OR uncompensated care OR indigent.mp OR uncompensated care.mp OR medical indigency).
Of 526 articles identified, 127 (24%) met inclusion/exclusion criteria. Articles were included if they focused on the medical and surgical care of adult (aged 18 to <65 years) uninsured patients in emergency settings. Excluded articles involved pediatric or geriatric populations, psychiatric and dental illnesses, and non-patient care issues.
Statements about uninsured patients presenting for emergency care that appeared without citation or that were not based on data provided in the articles were identified using a qualitative descriptive approach based in grounded theory. Each assumption was then addressed separately in searches for supporting data in national data sets, administrative data, and peer-reviewed literature.
Among the 127 identified articles, 53 had at least 1 assumption about uninsured ED patients, with a mean of 3 assumptions per article. Common assumptions supported by the evidence include assumptions that increasing numbers of uninsured patients present to the ED and that uninsured patients lack access to primary care. Available data support the statement that care in the ED is more expensive than office-based care when appropriate, but this is true for all ED users, insured and uninsured. Available data do not support assumptions that uninsured patients are a primary cause of ED overcrowding, present with less acute conditions than insured patients, or seek ED care primarily for convenience.
Some common assumptions regarding uninsured patients and their use of the ED are not well supported by current data.

0 Followers
 · 
76 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Americans who received public insurance under the Affordable Care Act use the emergency department more frequently than before they were insured. If newly enrolled patients cannot access primary care, and instead rely on the emergency department, they may not enjoy the full benefits of healthcare services.Objective To characterize reasons for emergency department utilization among American adults by insurance status and usual source of care.Design, Setting, and ParticipantsCross-sectional analysis of adult sample respondents to the 2013 National Health Interview Survey reporting one or more emergency department visits in the preceding twelve months.Main Outcomes and MeasuresAmong American emergency department users that reported no usual source of care and who reported relying on the emergency department, 27.7% (95% CI 23.6% to 32.2%) and 35.1% (95% 28.0% to 43.0%) noted at least one issue of access and none of acuity as a reason for their last emergency department visit, as compared to 17.7% (95% 16.3% to 19.2%) among those with a stable usual source of care.Conclusions and RelevanceWhile past research has shown that those who lack a stable usual source of care use the emergency department more often, this is the first population-level study to demonstrate their propensity for lack of access-based utilization. In the wake of the Affordable Care Act, emergency departments will need to evolve into outlets that service a wider range of healthcare needs rather than function in their current capacity, which is largely to address acute issues in isolation.
    American Journal of Emergency Medicine 11/2014; 33(2). DOI:10.1016/j.ajem.2014.11.006 · 1.15 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: It is a well-known fact that uninsured individuals in US are of lower socioeconomic status and that these individuals often are overrepresented at the emergency departments. We investigate if we find a similar pattern in Norway where health care is tax-financed, free of charge at the point of use, hospitals are publicly owned and funded by the government, and access to health care is (supposed to be) independent of socioeconomic status. We find substantial differences between socioeconomic groups in the number of emergency treatments relative to planned treatments, with patients with high income and tertiary education having considerably lower share of emergency treatments than patients with low income and primary education. This result suggests that lack of comprehensive health insurance is unlike to be the only reason why persons with low socioeconomic status are overrepresented in emercency departments.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Use of the hospital emergency department (ED) for medical conditions not likely to require immediate treatment is a controversial topic. It has been faulted for ED overcrowding, increased expenditures, and decreased quality of care. On the other hand, such avoidable ED utilization may be a manifestation of barriers to primary care access. Methods A random 10% subsample of all ED visits with unmasked variables, or approximately 7.2% of all ED visits in California between 2006 and 2010 are used in the analysis. Using panel data methods, we employ linear probability and fractional probit models with hospital fixed effects to analyze the associations between avoidable ED utilization in California and observable patient characteristics. We also test whether shorter estimated road distances to the hospital ED are correlated with non-urgent ED utilization, as defined by the New York University ED Algorithm. We then investigate whether proximity of a Federally Qualified Health Center (FQHC) is correlated with reductions in non-urgent ED utilization among Medicaid patients. Results We find that relative to the reference group of adults aged 35–64, younger patients generally have higher scores for non-urgent conditions and lower scores for urgent conditions. However, elderly patients (≥65) use the ED for conditions more likely to be urgent. Relative to male and white patients, respectively, female patients and all identified racial and ethnic minorities use the ED for conditions more likely to be non-urgent. Patients with non-commercial insurance coverage also use the ED for conditions more likely to be non-urgent. Medicare and Medicaid patients who live closer to the hospital ED have higher probability scores for non-emergent visits. However, among Medicaid enrollees, those who live in zip codes with an FQHC within 0.5 mile of the zip code population centroid visit the ED for medical conditions less likely to be non-emergent. Conclusions These patterns of ED utilization point to potential barriers to care among historically vulnerable groups, observable even when using rough estimates of travel distances and avoidable ED utilization. Electronic supplementary material The online version of this article (doi:10.1186/s12939-015-0158-y) contains supplementary material, which is available to authorized users.
    International Journal for Equity in Health 03/2015; 14. DOI:10.1186/s12939-015-0158-y · 1.71 Impact Factor