Abstract
Introduction
The increasing use of emergency departments (EDs) for nonemergent visits is overcrowding these facilities and potentially increasing the cost of care.1-3 While the magnitude of ED use has been well documented, little is known about the factors influencing these use patterns and even less is known about effective interventions.4,5 Our study was designed to contribute to a better understanding of the factors influencing these use patterns by conducting in-depth interviews with patients and documenting the demographic characteristics and insurance status of these patients.
Methods
Study Sample
This study was conducted at an urban hospital and was approved by the hospital’s institutional review board. On a week day over a continuous 24-hour period trained interviewers were in the ED. Patients were seen initially by a physician and/or a nurse. Patients who were medically or psychiatrically unstable, intoxicated, demented, or who did not speak English were not interviewed. Parents or guardians were asked to answer the questions for those younger than 18. Those patients participating in the study received a $10 gift card. During the 24-hour period, 232 patients were seen in the ED and 67 (29%) were interviewed. The hospital provided deidentified demographic data, reason for visit and facility and professional payment claims for all of the patients. To protect patient privacy, we did not link patient interview responses to the data provided by the hospital.
Study Design
The interviewers asked patients if they had a usual source of care, how often they sought medical care in the past 12 months, if they consulted anyone prior to going to the ED, health insurance status, educational level, and age. The interviewers also asked patients to tell them some of the reasons why they came to the ED. After patients answered this open-ended question, they were asked if in addition any of the following influenced their decision: no appointment needed, transportation availability, inability to get an appointment at their clinic, preferred to receive care in the ED, or because they thought they had a medical emergency.
Results
During this 24-hour study period, 91% of the 232 patients seen in the ED had health insurance. Almost half had Medicaid coverage (45%), 30% had employer-based health insurance, 25% Medicare, and less than 10% were uninsured. The patients were distributed across all age groups <18 years (21%), 18 to 26 years (12%), 27 to 35 years (19%), 36 to 50 years (12%), 51 to 65 years (15%), and >65 years (19%). Females comprised 52% of the patients and 47 (20%) patients were admitted to the hospital.
Table 1 shows that the 67 patients interviewed were similar to the overall 24-hour patient population in terms of age <18 years (15%), 18 to 26 years (21%), 27 to 35 years (10%), 36 to 50 years (15%), 51 to 65 years (21%), and >65 years (18%). The patients interviewed had a similar insurance status to the entire patient population with 38% covered by Medicaid, 38% by employer-based plans, 23% by Medicare, and 13% uninsured.
Patient Interview Responses.
Abbreviation: ED, emergency department.
Most patients (90%) listed a clinic as their usual source of care although 23% of these patients listed a clinic whose providers do not have privileges at this hospital. The majority of patients (79%) did speak with someone prior to seeking care in the ED and that was most often a family member (77%). Fewer patients spoke with their physician (15%) or nurse line (15%).
The most common reason patients gave for seeking care in the ED was that their condition was an emergency (72%). Patients also stated they were influenced by no appointment needed (28%), unable to get appointment or their clinic was closed (27%), preferred to go to ED (24%), and able to get a ride to ED (19%).
Discussion
The majority of patients interviewed reported they were in the ED because they thought their condition was an emergency. Patients do discuss their health conditions with others prior to going to the ED, but most do not consult health care personnel. Since most patients named a clinic as their usual source of care, informing patients that they can call the clinic or a nurse line for medical advice during and after business hours may reduce the number of nonemergent ED visits. In addition, clinics can advise patients to seek care at EDs where the clinics’ physicians have admitting privileges to improve continuity of care and access to electronic health records.
An important finding is that the majority of patients believed their condition was an emergency yet a third of them were unable to be seen in their clinic because of a lack of appointment availability or the clinic was closed. Also, a third of responders reported they had talked to their physician or a nurse prior to going to the ED. These findings suggest a need to re-evaluate concerns about ED use and consider the positive role of the ED as a safety net for clinics who do not have the capacity or cannot be open 24 hours a day.
This study is limited by the small number of patients interviewed but is enhanced by receiving all of the ED patients’ claims data. Future studies could include interventions at clinics to inform their patients of the availability of medical personnel after hours to determine the necessity of an ED visit.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.