Original Research
Does 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

https://doi.org/10.1016/j.annemergmed.2004.06.023Get rights and content

Study objective

We determined whether having a usual source of care or health insurance is associated with the likelihood of an emergency department (ED) visit.

Methods

This was a multivariate analysis of the 2000 to 2001 nationally representative Community Tracking Study Household Survey to assess the independent association of usual source of care, health insurance, income, and health status with the likelihood of making 1 or more ED visits in the previous year.

Results

Based on a sample of 49,603 adults, an estimated 45.3 million adults reported 79.6 million ED visits in the previous year; 83.1% of these visitors identified a usual source of care other than an ED. Persons with poor physical health status made 48.4% of visits. Adults without a usual source of care were less likely to have had an ED visit than those whose usual source of care was a private physician (odds ratio [OR] 0.75). Uninsured individuals were no more likely to have an ED visit than insured individuals. Poor physical health (OR 2.41), poor mental health (OR 1.51), 5 or more outpatient visits during the year (OR 4.05), and changes in insurance coverage (OR 1.14) or usual source of care (OR 1.32) during the year were associated with an ED visit. Enrollment in a health maintenance organization and satisfaction with one's physician were not independently associated with ED use.

Conclusion

ED users are similar to nonusers with regard to health insurance and usual source of care but are more likely to be in poor health and have experienced disruptions in regular care. The success of efforts to decrease ED use may depend on improving delivery of outpatient care.

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

References (59)

  • J.M. Gill et al.

    Disagreement among health care professionals about the urgent care needs of emergency department patients

    Ann Emerg Med

    (1996)
  • R.A. Lowe et al.

    Judging who needs emergency department care: a prerequisite for policy-making

    Am J Emerg Med

    (1997)
  • M.A. Rubin et al.

    Utilization of the emergency department by patients with minor complaints

    J Emerg Med

    (1995)
  • L.F. McCaig et al.

    National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary. Advance data from vital and health statistics; No 340

    (2004)
  • D.L. Washington et al.

    Next-day care for emergency department users with nonacute conditions: a randomized, controlled trial

    Ann Intern Med

    (2002)
  • K. Grumbach et al.

    Primary care and public emergency department overcrowding

    Am J Public Health

    (1993)
  • R.I. Haddy et al.

    Nonemergency emergency room use in patients with and without primary care physicians

    J Fam Pract

    (1987)

  • Measures to deal with emergency department overcrowding: American College of Emergency Physicians

    Ann Emerg Med

    (1990)
  • J. Billings et al.

    Emergency department use in New York City: a substitute for primary care?

    Issue Brief (Commonwealth Fund)

    (2000)
  • P.R. Torrens

    Variation among emergency room populations: a comparison of four hospitals in New York City

    Med Care

    (1970)
  • D.S. Jones et al.

    Lack of a regular source of care among children using a public hospital emergency department

    Pediatr Emerg Care

    (1999)
  • M. Prince et al.

    A study of “inappropriate” attendances to a paediatric accident and emergency department

    J Public Health Med

    (1992)
  • W.C. Stratmann et al.

    A study of consumer attitudes about health care: the role of the emergency room

    Med Care

    (1975)
  • J.M. Gill et al.

    Nonurgent use of hospital emergency departments: urgency from the patient's perspective

    J Fam Pract

    (1996)
  • P.J. Cunningham et al.

    The use of hospital emergency departments for nonurgent health problems: a national perspective

    Med Care Res Rev

    (1995)
  • G.E. Fryer et al.

    Variation in the ecology of medical care

    Ann Fam Med

    (2003)
  • D.M. Mirvis et al.

    TennCare: health system reform for Tennessee

    JAMA

    (1995)
  • R.E. Hurley et al.

    Gatekeeping the emergency department: impact of a Medicaid primary care case management program

    Health Care Manage Rev

    (1989)
  • J.H. Straus et al.

    Referrals from an emergency room to primary care practices at an urban hospital

    Am J Public Health

    (1983)

    • Cited by (132)

    • Invasive Management and In-Hospital Outcomes of Myocardial Infarction Patients in United States Safety-Net Hospitals

      2023, Cardiovascular Revascularization Medicine

    • The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study

      2021, Annals of Emergency Medicine

    • Impact of cash incentives for low-income individuals to seek a primary care visit on mental health outcomes: Evidence from a randomized controlled trial

      2020, Social Science and Medicine
      Citation Excerpt :

      Reasons for this observation are unclear, but researchers cite poor access to and low utilization of primary care as a possible cause. Lines et al. (2019) Prior research reports that individuals without a usual source of care provider or those who are dissatisfied with their provider are more likely to use the ED (Petersen et al., 1998; Petterson et al., 2009; Sarver et al., 2002; Weber et al., 2005). In addition, patients with perceived barriers (e.g., difficulty making appointments) to accessing a usual provider are also more likely to visit an ED.

    • Is Emergency Medicine the Right Choice for Me?

      2019, Journal of Emergency Medicine

    • Insurance Status and Access to Urgent Primary Care Follow-up After an Emergency Department Visit in 2016

      2018, Annals of Emergency Medicine

    • Predictors of self-harm emergency department visits in adolescents: A statewide longitudinal study

      2019, General Hospital Psychiatry
    View all citing articles on Scopus

    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.

    View full text
    Copyright © 2005 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.