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: 35.29). 10/2008; 300(16):1914-24. DOI: 10.1001/jama.300.16.1914
Source: PubMed


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 OR emergency OR Emergency Medicine) AND ( OR medically uninsured OR uncompensated care OR OR uncompensated 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.

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Available from: Rebecca M Cunningham, Jan 14, 2016
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    • "In fact, even when adjusting for insurance, those without a stable usual source of care are 1.5 to 2 times more likely to have used the ED specifically because they felt it was an accessible option rather than because they felt their condition warranted ED-level care. Thus, our results reinforce previous data showing insurance status to be a poor predictor of health care utilization patterns by itself [14] [19]. Furthermore, among those who lack a stable usual source of care, perceived access rather than acuity is the critical variable to consider in driving ED visits. "
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    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.
    Full-text · Article · Nov 2014 · American Journal of Emergency Medicine
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    • "The emergency department (ED), closely linked to the critical care setting, is widely used as first and last resort for acute as well as chronic disease management. In fact, with the advent of the economic recession in the U.S. and concomitant loss of health insurance in families, usage of the ED has increased tremendously [1] [2]. The ED and critical care settings provide a unique clinical venue to develop, test and implement novel biomarkers that can be cost-effective and rapid in their ability to manage acute as well as chronic disease processes with acute exacerbations. "
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    ABSTRACT: The potential of nitric oxide (NO) as a rapid assay biomarker, one that could provide a quantum leap in acute care, remains largely untapped. NO plays a crucial role as bronchodilator, vasodilator and inflammatory mediator. The main objective of this review is to demonstrate how NO is a molecule of heavy interest in various acute disease states along the emergency department and critical care spectrum: respiratory infections, central nervous system infections, asthma, acute kidney injury, sepsis, septic shock, and myocardial ischemia, to name just a few. We discuss how NO and its oxidative metabolites, nitrite and nitrate, are readily detectable in several body compartments and fluids, and as such they are associated with many of the pathophysiological processes mentioned above. With methods such as high performance liquid chromatography and chemiluminescence these entities are relatively easy and inexpensive to analyze. Emphasis is placed on diagnostic rapidity, as this relates directly to quality of care in acute care situations. Further, a rationale is provided for more bench, translational and clinical research in the field of NO biomarkers for such settings. Developing standard protocols for the aforementioned disease states, centered on concentrations of NO and its metabolites, can prove to revolutionize diagnostics and prognostication along a spectrum of clinical care. We present a strong case for developing these biomarkers more as point-of-care assays with potential of color gradient test strips for rapid screening of disease entities in acute care and beyond. This will be relevant to global health.
    Full-text · Article · Mar 2013 · The Open Biochemistry Journal
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    • "Previous have evaluated characteristics of frequent ED users [17] [18] [19]. Although many organizations have discussed limited access to care and the demographics of the insured population as a whole, little national data are available regarding resource utilization including rates of testing, procedures, medication administration, and disposition in the ED by insurance coverage [2] [8] [13] [14] [15] [16] [20] [21] [22] [23] [24] [25]. "
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    ABSTRACT: Background: For nearly 51 million persons in the United States who lack health care insurance, the emergency department (ED) functions as a safety net where no patient is denied care based on ability to pay, and much public rhetoric has characterized ED utilization by uninsured patients. We estimated national ED utilization by uninsured patients and compared uninsured and insured ED patients in terms of demographics, diagnostic testing, disposition and final diagnoses. Methods: We analyzed data from the National Hospital Ambulatory Medical Care Survey (2006-2009) stratified by insurance status. Demographic data, diagnoses, testing, and procedures performed in the ED were tabulated for each visit. Weighted percentages provided by National Hospital Ambulatory Medical Care Survey were used to estimate national rates for each variable, and multivariate models were constructed for predicting testing, procedures, and admission. Results: The 135085 ED visits represent 475 million patients visits, of which 78.9 million (16.6%) were uninsured. Compared with insured patients, uninsured patients were more often male (51.1% vs 44.3%) and younger (age 18-44 years, 66.2% vs 35.4%). Uninsured patients had lower rates of circulatory/cardiovascular (7.5% vs 4.1%) and respiratory diagnoses (14.6% vs 11.8%). Uninsured patients had fewer diagnostic tests and procedures and fewer hospital admissions than those with insurance. In our multivariate models, insurance status was predictive of testing and procedures but not hospital admission. Conclusions: Uninsured patients account for approximately 20 million or 1 in 6 ED visits annually in the United States and have differences in demographics, diagnoses, and ED utilization patterns from those with insurance.
    Full-text · Article · Jan 2013 · The American journal of emergency medicine
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