Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia 30310, USA.
The Journal of Rural Health (Impact Factor: 1.77). 02/2009; 25(1):8-16. DOI: 10.1111/j.1748-0361.2009.00193.x
Source: PubMed

ABSTRACT Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities.
We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence.
We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits.
Counties without a CHC primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11-1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02-1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92-1.22).
The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.


Available from: George Rust, Aug 15, 2014
1 Follower
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Nonurgent use of hospital emergency departments (ED) is a controversial topic. It is thought to increase healthcare costs and reduce quality, but is also considered a symptom of unequal access to health care. In this article, we investigate whether convenience (as proxied by travel distances to the hospital ED and to the closest federally qualified health center) is associated with nonurgent ED use, and whether evidence of health disparities exist in the way vulnerable populations use the hospital ED for medical care in South Carolina. Our data includes 6,592,501 ED visits in South Carolina between 2005 and 2010 from the South Carolina Budget Control Board and Office of Research and Statistics. All ED visits by South Carolina residents with unmasked variables and nonmissing urgency measures, or approximately 76 % of all ED visits, are used in the analysis. We perform multivariable linear regressions to estimate correlations between (1) travel distances and observable sociodemographic characteristics and (2) measures of nonurgent ED use or frequent nonurgent ED use, as defined by the New York University ED Algorithm. Patients with commercial private insurance, self-pay patients, and patients with other payment sources have lower measures of nonurgent ED use the further away the ED facility is from the patients' home address. Vulnerable populations, particularly African American and Medicaid patients, have higher measures of nonurgent ED scores, and are more frequent users of the ED for both nonurgent and urgent reasons in South Carolina. At the same time, African Americans visit the hospital ED for medical conditions with higher primary care-preventable scores. Contrary to popular belief, convenient access (in terms of travel distances) to hospital ED is correlated with less-urgent ED use among privately insured patients and self-pay patients in South Carolina, but not publicly insured patients. Unequal access to primary care appears to exist, as suggested by African American patients' use of the hospital ED for primary care-treatable conditions while experiencing more frequent and more severe primary care-preventable conditions.
    BMC Health Services Research 05/2015; 15(1):203. DOI:10.1186/s12913-015-0864-6 · 1.66 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This paper uses the rollout of the first Community Health Centers (CHCs) to study the longer-term health effects of increasing access to primary care. Within ten years of their establishment, CHCs are associated with a reduction in age-adjusted mortality rates of almost 2 percent among those 50 and older. The implied 7 to 13 percent decrease in one-year mortality risk among beneficiaries amounts to 20 to 40 percent of the 1966 poor/non-poor mortality gap for this age group. Large effects for those 65 and older suggest that increased access to primary care has longer-term benefits, even for populations with near universal health insurance. the NICHD (T32 HD0007339) as a UM Population Studies Center Trainee. We are grateful to Doug Almond, Hilary Hoynes, and Diane Schanzenbach for sharing the Regional Economic Information System (REIS) data for the period of 1959 to 1978; Amy Finkelstein for sharing the American Hospital Association (AHA) Annual Survey data from 1948 to 1974; Jean Roth for sharing the AHA data from 1976 to 1990; Cynthia Severt and the University of Wisconsin DISC for helping us locate and compile the OEO survey data; and Cheryl Sutherland and Jeffrey Hackett from NORC for helping us locate the restricted geographic identifiers in the SHSUE. We are also grateful for helpful comments from
    American Economic Review 03/2015; 105(3). DOI:10.1257/aer.20120070 · 2.69 Impact Factor
  • [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(1). DOI:10.1186/s12939-015-0158-y · 1.71 Impact Factor