Original ResearchDoes lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study
Introduction
Between 1992 and 2002, emergency department (ED) use climbed 23%, from 89.8 million to 110 million visits.1 Increasing use of the ED is often attributed to visits by individuals who lack a usual source of care or have no health insurance.2, 3, 4, 5, 6, 7 The data for either contention are inconclusive. Although several studies suggest that persons without a usual source of care are disproportionately represented in ED populations,3, 4, 8, 9, 10, 11, 12, 13 other studies, conducted in EDs with different populations, disagree.12, 14, 15, 16, 17, 18 Data about the association of insurance coverage and ED use are surprisingly sparse and also contradictory.9, 13, 15, 18, 19, 20, 21
The literature on ED utilization is limited by the fact that most studies are conducted at an individual department and often focus on special populations, such as frequent users or patients with minor illnesses. More important, these studies include only ED visitors, not the general population of health care recipients. Therefore, they cannot assess whether persons with a usual source of care, insurance, or any other characteristic are more or less likely to use the ED.
Understanding the true relationship between patient characteristics and ED use is essential to crafting successful policies and appropriately directing resources to alleviate ED crowding while improving access to needed health care. Many insurance programs, and particularly public and private health maintenance organizations (HMOs), require beneficiaries to have a primary physician.22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 Although having a primary physician may be expected to improve overall health and health care, the continued increase in ED visits implies that such programs have not had a substantial impact on overall ED use.23, 24, 26, 27, 34, 35 Understanding the association between having a usual source of care and ED use, as well as the association of other patient characteristics with ED visits, is of critical importance in determining whether such policies should be continued or whether more effective strategies could be designed.
Furthermore, a possibly mistaken belief that individuals who use the ED do not have primary physicians or insurance may contribute to a perception by the public and by policymakers that ED crowding is caused by, and affects, only a relatively small, disenfranchised portion of the US population. Additionally, it may result in a perception by hospital administrators that emergency patients are not as valuable to the institution as elective admissions.
We analyzed a large, nationally representative sample that contained information on usual source of care, insurance status, demographic characteristics, health status, health care use, and attitudes toward the health care delivery system and included ED users and nonusers. The primary research question was whether individuals without a usual source of care and individuals without insurance were more likely to have had an ED visit in the previous year compared with individuals with a usual source of care or with insurance. We also sought to determine whether other characteristics—income, health status, disruptions in insurance or regular care, and specific features of the usual source of care—distinguish those who used the ED from those who did not.
Section snippets
Materials and methods
The Community Tracking Study Household Survey, conducted by the Center for Studying Health System Change, is designed to measure health care use and the characteristics associated with use, such as income, education, insurance, and health status.36 The Center for Studying Health System Change, established in 1995, is a nonpartisan policy research organization located in Washington, DC, that designs and conducts studies focused on the US health care system to inform the thinking and decisions of
Results
A usual source of care other than an ED was identified by 82.7% of the adult population (Table 1). An ED was the usual source of care for 2.4% of the adult population, and 14.5% did not identify a usual source of care.
An estimated 45.3 million adults reported at least 1 ED visit, resulting in 79.6 million reported visits from July 2000 through June 2001 (Table 2). Among those who used the ED, 83.1% of patients identified a usual source of care other than an ED and accounted for 82.4% of
Limitations
Similar to other survey data, our data may be limited by recall bias and lack of response. The sampling and weighting methods of the Community Tracking Study, however, were designed to include a nationally representative sample and to account for differences in likelihood of selection and differential response rates. The study sample could also potentially underrepresent homeless persons, who might account for a disproportionate share of ED visits.45 Our estimates of total ED visits and payer
Discussion
In a nationally representative sample of adults, most ED visits were by persons who had health insurance and a usual source of care. Persons without a usual source of care were less likely than those with a usual source of care to have had an ED visit. Persons who identified the ED as their usual source of care were (unsurprisingly) more likely to have had an ED visit, although they constituted only 5% of users of the ED and accounted for only 7% of all ED visits. Persons without insurance were
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Author contributions: EJW, JAS, KAH, DCC, and MLC conceived the study, determined the theoretical model, and interpreted the results. EJW, JAS, and KAH designed the analyses. KAH and JAS provided statistical consultation; KAH programmed the data. EJW drafted the manuscript with contributions from JAS and KAH. All authors contributed substantially to its revision. EJW takes responsibility for the paper as a whole.
The interpretations and opinions are those of the authors and may not necessarily reflect those of The Robert Wood Johnson Foundation or the University of California, San Francisco.
The authors report this study did not receive any outside funding or support.
Reprints not available from the authors.