Annals of Emergency Medicine
Volume 45, Issue 1 , Pages 13-14, January 2005

Rising utilization of US emergency departments: Maybe it is time to stop blaming the patients

  • Michael J. Schull, MD, MSc

      Affiliations

    • Corresponding Author InformationAddress for correspondence: Michael J. Schull, MD, MSc, G-106, Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, Canada, M4N 3M5; 416-480-6100 ext. 3793, fax 416-480-6048

From the Institute for Clinical Evaluative Sciences; the Clinical Epidemiology Unit and Department of Emergency Services, Sunnybrook and Women's College Health Sciences Centre; and the Department of Medicine, University of Toronto, Toronto, Ontario, Canada

published online 15 November 2004.

See related article, p. 4.

[Ann Emerg Med. 2005;45:13-14.]

Article Outline

 

Although the root cause of increasing emergency department (ED) utilization and crowding appears elusive to some observers, to others it seems quite obvious: it's all those darn patients. And many of them, so the theory goes, just don't need to be there; the visits could be diverted to primary care services.

In the United States, this seductive argument often focuses on the underinsured or uninsured, individuals who are less likely to have access to primary care. These individuals are thought to frequently use the ED for problems that could be better handled in primary care settings. In this model, improving access to a regular primary caregiver would mean reduced utilization of EDs. The study by Weber et al1 in this issue of Annals throws cold water on this theory.

In this study, a population-based sample of some 50,000 US adults was interviewed by telephone. Approximately 83% of respondents had a usual source of medical care, and they accounted for about 83% of all ED visits. Approximately 17% had no usual source of care (or used the ED for that purpose), and they accounted for about 17% of all ED visits. Although homeless or very-low income individuals may be underrepresented in a telephone survey, essentially what this means is that patients utilizing EDs across the United States are no more likely to lack a usual source of medical care than is the rest of the general population.

Furthermore, when patient demographics, income, and health status were taken into account, a lack of health insurance or the absence of a usual source of care were not associated with the likelihood of visiting an ED. However, lower income, poor physical or mental health, and unmet health needs were all independent predictors of visiting an ED. What does all this mean? It means that being in ill health, being poor, or having unmet health needs are important predictors of who will use an ED, regardless of insurance status or having a usual source of medical care.

This result is likely not too surprising to physicians working in other countries where there are fewer uninsured patients and hence greater access to primary care,2 but which, like the United States, have seen increasing ED utilization and crowding.3, 4 On the basis of the experience in these countries and the results of Weber et al's1 study, reducing or even slowing the increase in ED utilization may not result simply from wider health insurance coverage or ensuring more people have access to primary care. The problem of utilization and crowding is likely much more complex, for several reasons.

First, having a usual source of medical care and having one available when you need them are two different things. Weber et al's1 results suggest that, for a substantial number of ED users, existing primary care services are not accessible quickly enough when they are needed, or are not fulfilling patients' expectations even when they are. Second, although some injuries and illnesses clearly can be fully dealt with in primary care settings, these are not the patients who lead to ED crowding or who represent the important part of the burden of increased utilization. The patients who lead to crowding and who tax ED resources are acutely ill and often need admission.5 These patients cannot be safely treated in primary care settings. However, better community-based management of chronic illnesses and mental health could possibly avoid exacerbations leading to ED visits.

Achieving this will require more than just more family physicians or extended clinic hours. It will require that patients have ready access to community-based primary care using evidence-based preventive measures, affordable pharmaceutical plans, and rapid access to appropriate diagnostic tests and specialist consultation and follow-up. In the short-term, progress could be made with simpler measures like expanded influenza vaccination campaigns6 (especially among the elderly), better chronic disease management in the community, or making essential drugs more affordable. But making the widespread primary care reforms necessary to meaningfully reduce ED utilization would be complex and expensive, however beneficial for patients and the health system. For the foreseeable future then, it is likely that most ED patients will continue to need the ED.

But is this such a bad thing? Weber et al's1 survey tells us that the ED patient population looks pretty similar to the general US population in terms of their health insurance coverage, and that those who end up in an ED have poor health and unmet health needs. That sounds like pretty rational utilization. The problem is not the patients; the problem is that our EDs and hospitals are not able to cope with the patient load. In the short term it may be more fruitful to focus on improving ED systems to cope with increasing utilization rather than engaging in more hand wringing about ways to divert ED patients elsewhere.

Back to Article Outline

References 

  1. Weber EJ, Showstack JA, Hunt KA, et al. 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. Ann Emerg Med. 2005;45:4–12
  2. Schoen C, Doty MM. Inequities in access to medical care in five countries: findings from the 2001 Commonwealth Fund International Health Policy Survey. Health Policy. 2004;67:309–322
  3. Richardson SK. Increasing patient numbers: the implications for New Zealand emergency departments. Accid Emerg Nurs. 1999;7:158–163
  4. Schull MJ, Szalai J, Schwartz B, et al. Emergency department overcrowding following systematic hospital restructuring: trends at twenty hospitals over ten years. Acad Emerg Med. 2001;8:1037–1043
  5. Schull M, Lazier K, Vermeulen M, et al. Emergency department contributors to ambulance diversion: a quantitative analysis. Ann Emerg Med. 2003;41:467–476
  6. Nichol KL, Nordin J, Mullooly J, et al. Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. N Engl J Med. 2003;348:1322–1332

 Dr. Schull has a Career Award from The Canadian Institutes of Health Research and the Peter Lougheed Medical Research Foundation.Reprints not available from the author.

PII: S0196-0644(04)01492-1

doi:10.1016/j.annemergmed.2004.09.027

Refers to article:

  • 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 , 25 October 2004

    Ellen J. Weber, Jonathan A. Showstack, Kelly A. Hunt, David C. Colby, Michael L. Callaham
    Annals of Emergency Medicine January 2005 (Vol. 45, Issue 1, Pages 4-12)

Annals of Emergency Medicine
Volume 45, Issue 1 , Pages 13-14, January 2005

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