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

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

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.

Children's use of emergency departments for asthma: persistent barriers or acute need?

Our objective was to explore, in a predominantly Latino inner-city population, why caregivers bring their children with asthma to the ED (emergency department). We conducted bilingual parent surveys and medical chart abstractions of a consecutive ED sample consisting of 234 children with asthma (69% Latino; 54% Spanish-speaking) and their caregivers. Outcome measures included: (1) the acute need for ED services based on objective physiological measures, (2) the extent to which these children experienced barriers to quality primary care for asthma before the ED visit, and (3) the relative importance caregivers assigned to worsening symptoms versus perceived barriers to non-ED care when deciding to bring their child to the ED. Most children had moderate or severe asthma attacks. In the prior month, only 33% went to a primary care provider, 83% had used a bronchodilator, and 63%, an age-appropriate spacer device. Seventy-five percent of caregivers cited perceived acute need, instead of barriers to primary care, as the most important reason for using the ED. This perception of acute need was associated with moderate or severe asthma attacks according to objective physiological measures, after controlling for health and sociodemographic characteristics. Children with asthma who use the ED encounter barriers to primary care, but caregivers' perception of acute need--validated by independent measures of attack severity--dominates caregivers' decision to use the ED. Ensuring continuity of care for children with asthma would involve not only improving various aspects of access to and quality of primary non-ED care--including parent education about early recognition and treatment of asthma attacks--but also providing families with practical low-cost alternatives for 24-hour care and assuring linkages between the ED and sources of primary care.

[Emergency department utilization by children aged less than two years old]

BACKGROUND

Emergency department visits are rising although birth rate is decreasing.

OBJECTIVE

To compare emergency department.(ED) utilization in the cohorts of children born in 1991 and 1996 in a health district.

METHOD

We performed a two-year retrospective cohort study in the health district of Mieres (Spain). All children born in the health district in 1991 (n 600) and 1996 (n 423) were included. The number of visits to the ED was obtained and the frequency and mean number of visits in the first 2 years of life were calculated according to age, sex, and area of residence.

RESULTS

The gross number of visits did not vary (1991: 852; 1996: 853), despite a decrease in birth rate. The number of children who attended the ED at least once increased by 34.8 % (1991, 60.6 %; 1996, 82 %) and the frequency of visits increased by 41.7 % (1991, 142.2 %; 1996, 201.4 %). More than 60 % of visits were made by 20 % (1991) of the children and by 29 % (1996). The percentage of children who attended the ED, the frequency rate and the mean number of visits were significantly higher in the municipality nearest the hospital than in the remaining municipalities in the health district.

CONCLUSIONS

Although the gross number of visits to the ED remained unchanged, ED utilization increased substantially in only 5 years.

Safely directing patients to appropriate levels of care: guideline-driven triage in the emergency service

STUDY OBJECTIVE

We sought to develop and validate standardized clinical criteria to identify patients presenting to the emergency department whose care may be safely deferred to a later date in a nonemergency setting.

METHODS

Using a modified Delphi process, a 17-member multidisciplinary physician panel developed explicit, standardized, deferred-care criteria. In a prospective cohort design, emergency nurses at a tertiary care Veterans Administration (VA) Medical Center, using the criteria, screened 1,187 consecutive ambulatory adult patients presenting with abdominal pain, musculoskeletal symptoms, or respiratory infection symptoms. Patients meeting deferred-care criteria were offered the option of an appointment within 1 week in the ambulatory care clinic at the study site; all other patients were offered same-day care. As outcome measures, we assessed nonelective hospitalizations for related conditions occurring within 7 days of evaluation at our facility or any other VA facility within a 300-mile radius, and we assessed 30-day all-cause mortality.

RESULTS

Two hundred twenty-six (19%) patients met screening criteria for deferred care. Patients meeting deferred-care criteria experienced zero (95% confidence interval, 0% to 1.2%) related nonelective VA hospitalizations within 7 days of evaluation, and none died within 30 days. By contrast, 68 (7%) of 961 (95% confidence interval, 5.5% to 8.9%) patients who did not meet deferred-care criteria were hospitalized nonelectively for related conditions, and 5 (0.5%) died.

CONCLUSION

By using hospitalization and 30-day mortality as safety gauges, standardized clinical criteria can identify, at presentation, VA ED users who may be safely cared for at a later date in a nonemergency setting. These guidelines apply to a significant proportion of VA ED users with common ambulatory conditions. These criteria deserve testing in other ED settings.

Does this patient need to be evaluated today? Designing a guideline-driven triage process to determine the timing of care for adults with respiratory infection symptoms

BACKGROUND

Physicians and nurses often make judgments about the urgency with which patients require evaluation, yet few explicit process-of-care criteria are available to guide these decisions. Using a multidisciplinary expert physician panel and explicit, quantitative group judgment methods, standardized, clinically detailed deferred care criteria were developed to guide emergency department and ambulatory care triage decisions for same-day versus deferred care for patients with respiratory infection symptoms.

METHODS

Using a modified Delphi process, an eight-member multidisciplinary expert physician panel rated the safety of deferred care for standardized clinical scenarios. The ratings were converted into explicit criteria and then compared with usual implicit judgment in terms of nurse triage times.

RESULTS

The panel achieved 100% consensus on 36 critical clinical factors, each of which precludes deferring care for a patient with respiratory infection symptoms. Based on combinations of 12 additional clinical factors, 48 clinical scenarios were created that the panel rated for deferred care safety. Panelists' ratings agreed for 90% of clinical scenarios. These were formatted into screening criteria. Near-perfect interrater agreement (kappa = 0.9) was found in reproducibility testing. The difference in mean nurse triage times using the criteria compared with implicit nurse judgment was 0.4 minutes (95% confidence interval = -2.1 to 2.9 minutes).

CONCLUSIONS

Application of explicit criteria for deferring care of patients with respiratory infection symptoms did not lengthen triage time. This approach may facilitate more efficient resource management for ambulatory settings. However, widespread use before these criteria's, our systematic criteria-based triage should be validated in multicenter clinical trials against an outcome standard and the more common implicit approach.

Primary care physician and patient factors that result in patients seeking emergency care in a hospital setting: the patient's perspective

Much has been written about "abuse" and "overutilization" of Emergency Departments (EDs). We undertook to study, from the patient's perspective, physician and patient factors that influence the patient's decision to seek ED care. The study was designed as a convenience cohort, multi-centre survey, conducted in 13 hospitals in the Greater Toronto Area. In our study group of 948, most ambulatory patients (93%) seeking care in an ED have a primary care physician. From the patient's perspective, most (76%) primary care physicians are not educating their patients about which situations warrant ED care and up to 54% are not informing their patients about which services are offered in the office. As many as 55% of patients presented to the ED because it was more convenient. Only a minority (23%) of patients felt their acuity of illness warranted an ED visit. Primary care physicians need to play a stronger role in educating their patients about the utilization of emergency care and the services offered in the office setting.

Patterns of visits to hospital-based emergency rooms

What are the functions of hospital emergency care in our society? How are these functions associated with the characteristics of emergency room users, their environment and with other available medical resources? To answer these questions, an ecological conceptual framework has been developed, along with a procedure which clearly distinguishes between the sources of individual variation (user characteristics) and ecological variation (the users' environment and available medical resources). Four different functions have been identified: (1) care of critical or urgent cases requiring treatment only available in a hospital, (2) care of urgent cases requiring treatment also available elsewhere than in a hospital, (3) care of non-urgent cases requiring treatment only available in a hospital and (4) care of non-urgent cases requiring treatment also available elsewhere than in a hospital. The ecological units selected for this study do not differ statistically with regard to the frequency with which emergency rooms are used for these four functions. However, certain individual factors predicting frequency of utilization do differ depending on the unit; for example, patient health status is not uniformly related to the use of emergency rooms for non-urgent reasons in all units. This association is particularly weak in socio-economically deprived units and more significant at higher socio-economic levels.

Medicaid HMO enrollees in the emergency room: use of nonemergency care

Medicaid managed care is generally acknowledged to reduce the use of emergency departments (EDs). Yet some studies of Medicaid managed care have shown no change in ED use, and others show wide variation across plans. Because emergency departments may not be the best place to deliver nonemergency care, it is useful to understand the characteristics of enrollees associated with a lower likelihood of ED use for nonurgent conditions. A recent study of Medicaid enrollees in a large Colorado health maintenance organization (HMO) revealed several sociological and psychological factors associated with nonemergency ED visits. The study found that nonemergency visits by people who are female, older, more satisfied with the HMO and their doctor, and enrolled longer in the HMO are less likely to visit the ED, whereas visits on weekends and those by people who live farther from their physicians and people who have more inpatient hospital admissions are more likely to be to the ED.

Health care utilization and health status in high-risk children randomized to receive group or individual well child care

OBJECTIVE

To determine if health care utilization and health status among high-risk children is modified by the use of group well child care (GWCC) as compared with traditional one-to-one individual well child care (IWCC).

STUDY DESIGN

Randomized controlled trial.

PARTICIPANTS

Children less than 4 months old from families with at least one of the following maternal risk factors: poverty, single marital status, age <20 years at delivery, less than a high school education, previous substance abuse, or history of abuse as a child.

SETTING

Two urban, university pediatric clinics in Seattle, Washington.

INTERVENTIONS

Children were randomized to receive GWCC or IWCC at the time of enrollment. Health supervision visits with two study nurse practitioners were scheduled at 4, 5, 6, 8, 10, 12, and 15 months of age. GWCC study visits consisted of a group discussion of age-appropriate child-rearing issues, along with a physical examination, health screening, and immunizations. Health care utilization among children receiving GWCC and those randomized to IWCC was assessed using the following measures: compliance with study visits, compliance with any age-appropriate health supervision visit, emergency department utilization, and immunization rates (defined as the proportion of children in each group who had received all recommended vaccines by 1 year of age). Provider time for GWCC and IWCC study visits was also recorded. Health status was measured using Stein's Functional Status IIR, completed by the mothers of study patients when their children completed the study at 15 months of age.

RESULTS

A total of 106 children received GWCC, whereas 104 were randomized to IWCC. Compliance with scheduled study visits was 47% for GWCC patients and 54% for IWCC recipients; overall compliance with any age-appropriate health supervision visit was 68% and 66%, respectively. Provider time was similar for GWCC and IWCC visits. By the age of 1 year, 67% of GWCC recipients and 73% of those receiving IWCC had received three DTP/DT, three OPV/IPV, three Hib, and three hepatitis B immunizations. A total of 242 emergency department visits were made by study patients during their enrollment in the project; there was no difference in the average number of visits between GWCC or IWCC children. However, children receiving IWCC were more likely to have at least one emergency department visit than GWCC recipients. At the conclusion of the project, health status, as measured by the Functional Status IIR, was similar in GWCC and IWCC patients (mean scores 92.4 +/- 1.4 and 92.5 +/- 1.1, respectively).

CONCLUSIONS

Health care utilization and health status was similar in high-risk children whether they received GWCC or IWCC. GWCC is a viable format for health supervision visits in this population.

Determinants of emergency department use: are race and ethnicity important?

STUDY OBJECTIVE

To determine whether race/ethnicity is an important determinant of emergency department use.

METHODS

We conducted a cross-sectional survey in a public ED to determine self-reported ED visits over the preceding 3 months. The study group comprised consecutive ambulatory patients (N = 1,049) with nonemergency medical problems.

RESULTS

Blacks, whites, and Hispanics were equally likely to report one or more visits to an ED in the 3 months before study enrollment. Blacks were the most likely to report two or more ED visits in the preceding 3 months (19.0%), followed by whites (13.5%) and Hispanics (11.4%) (P = .01; unadjusted odds ratio, 1.82 for blacks versus Hispanics). In multivariate analysis, older age (P < .001), health insurance coverage (P < .001), regular source of care (P < .001), and difficulty obtaining transportation to a physician's office (P = .011) were positively associated with two or more previous ED visits. After adjustment for these variables, race/ethnicity was not significantly associated with ED use (P = .23; adjusted odds ratio for blacks versus Hispanics, 1.48 [95% confidence interval, .95 to 2.30]).

CONCLUSION

Race/ethnicity was not an important determinant of ED use after adjustment for age, health insurance coverage, regular source of care, and barriers to health care. Population-based studies of ED use should be conducted to further evaluate whether racial/ethnic differences in ED use exist that are not explained by differences in demographics, health, socioeconomic status, access to care, or other determinants of ED use.

The costs of visits to emergency departments

BACKGROUND

Many visits to emergency departments are for minor medical problems, and these visits are criticized as being expensive and economically inefficient. This study examines the marginal costs (the extra costs for an additional visit) of emergency department visits.

METHODS

Monthly data on the costs of hospital and physicians' services from 1991 through 1993 were obtained from a sample of six community hospitals in Michigan. The data were analyzed with ordinary least-squares regression techniques to determine the ratio of marginal to average costs. Average and marginal costs were then determined for 24,010 visits during 12 randomly selected weeks in 1993. A visit by an individual patient was the unit analysis, and visits were classified as nonurgent, semiurgent, or urgent according to explicit criteria. Costs and charges were determined for all visits and were classified according to the degree of urgency.

RESULTS

For all emergency department visits, the average charge was $383, the average cost was $209, and the marginal cost was $88 (42 percent of the average cost). Thirty-two percent of the visits were classified as nonurgent, 26 percent as semiurgent, and 42 percent as urgent. For nonurgent visits, the average charge was $124, the average cost was $62, and the marginal cost was only $24. For semiurgent visits, the average charge was $312, the average cost was $159, and the marginal cost was $67. For urgent visits, the average charge was $621, the average cost was $351, and the marginal cost was $148.

CONCLUSIONS

The true costs of nonurgent care in the emergency department are relatively low. The potential savings from a diversion of nonurgent visits to private physicians' offices may therefore be much less than is widely believed.

Determinants of emergency department use by ambulatory patients at an urban public hospital

STUDY OBJECTIVE

To determine emergency department patients' perceptions of their illness urgency, their attempts to get care elsewhere, and the proportion of patients referred to the ED.

DESIGN

Cross-sectional design with self-administered questionnaires or interviews.

SETTING

Public hospital in Los Angeles County, California.

PARTICIPANTS

Consecutive ambulatory patients totaling 1,190.

RESULTS

Most patients thought that they required immediate medical attention, even if they said that their condition was not serious, painful, or debilitating. Half of all patients sought care elsewhere before coming to the ED, and 38.2% had seen a doctor. Forty-four percent of all patients said they were referred to the ED by a doctor or a nurse. Referred patients had illness acuteness similar to that of patients who came to the ED on their own.

CONCLUSION

In addition to their lack of access to other providers, patients' perceived need for immediate care and referrals by health professionals contribute to ED use for nonemergency conditions.

Nonurgent use of the emergency department: appropriate or not?

People often assume that the use of hospital emergency departments for nonurgent problems is inappropriate. To test this assumption, several questions must be answered. These include, "How do we determine what is appropriate use of an ED?"; "How can we measure urgency in the ED?"; "Is care for nonurgent problems less effective in an ED than in a primary care facility?"; and "Is nonurgent care more costly in an ED than in a primary care facility?" These four questions are addressed, and suggestions for future research that would help answer these questions are made.

What is an emergency? The judgments of two physicians

How an "emergency" is defined by an internist and an emergency physician is the focus of this paper, which originated in a study of nonemergency use of two urban hospital emergency departments by Medicaid, uninsured, and commercially insured patients. Retrospective medical record reviews of 219 patients conducted independently by these two physicians revealed agreement on clinical impressions but dramatic divergence regarding the designation of visits as "emergencies" and the appropriate treatment location. Subsequent interviews with each physician suggested that the divergence of opinion regarding the definition of a true emergency is ideologically motivated and specialty related. Considered in the context of ED studies, which show enormous variations in the percentage of cases judged to be "emergencies," defining an "emergency" may be more a matter of physician training, specialty, and beliefs than of science. Further analysis revealed no correlation between patients' perceptions and either physician's judgments concerning what constitutes an "emergency," suggesting that neither specialty's assumptions are sensitive to patients' experience of the physical pain and anxiety that frequently lead them to present to the ED.

Compliance with emergency department referral: the effect of computerized discharge instructions

STUDY OBJECTIVE

To examine the effect of computerized discharge instructions on emergency department patient referral recommendations.

DESIGN

Prospective, descriptive analysis and clinical trial.

SETTING

Emergency medicine residency-affiliated urban hospital with 568 beds and 29,000 annual visits.

TYPE OF PARTICIPANTS

One thousand ED patients discharged to an outpatient referral network during a six-week period.

INTERVENTION

Mandatory referral was provided in written or computerized (Logicare Corp, Eau Claire, Wisconsin) format for each 500-patient group. Demographic data and compliance, measured as appointment completion within 30 days, were analyzed using chi 2 with Yates' correction, Fisher's exact, and odds ratio comparisons (P < .05, 95% confidence interval).

MEASUREMENTS AND MAIN RESULTS

The institution of computerized discharge instructions resulted in increased overall patient compliance from 26.2% to 36.2% (P < .0008) with odds ratio of 1.59 (1.2 to 2.1). Subset analysis showed increased compliance in patients who were more than 40 years old (32.5% to 61.1%), were female (28.7% to 39.7%) with a private physician (36.4% to 53.9%), established hospital relationship (26.1% to 38.9%), had nonurgent complaints (26.5% to 36.2%), were specifically diagnosed with strain or contusion (17.0% to 36.8%), or were referred to obstetrics/gynecology clinic (13.2% to 48.6%) (P < .001).

CONCLUSION

Computerized discharge instructions were associated with improved compliance with ED referral recommendations, based on historic and contemporary controls.

Primary care and public emergency department overcrowding

OBJECTIVES

Our objective was to evaluate whether referral to primary care settings would be clinically appropriate for and acceptable to patients waiting for emergency department care for nonemergency conditions.

METHODS

We studied 700 patients waiting for emergency department care at a public hospital. Access to alternative sources of medical care, clinical appropriateness of emergency department use, and patients' willingness to use nonemergency services were measured and compared between patients with and without a regular source of care.

RESULTS

Nearly half (45%) of the patients cited access barriers to primary care as their reason for using the emergency department. Only 13% of the patients waiting for care had conditions that were clinically appropriate for emergency department services. Patients with a regular source of care used the emergency department more appropriately than did patients without a regular source of care. Thirty-eight percent of the patients expressed a willingness to trade their emergency department visit for an appointment with a physician within 3 days.

CONCLUSIONS

Public emergency departments could refer large numbers of patients to appointments at primary care facilities. This alternative would be viable only if the availability and coordination of primary care services were enhanced for low-income populations.

Psychosocial factors influencing non-urgent use of the emergency room: a review of the literature and recommendations for research and improved service delivery

Despite dramatic increases in use of hospital emergency rooms (ERs) since the 1950s, an estimated 85% of ER visits are made for non-life-threatening reasons. Using a modified version of the Andersen and Newman model of health care utilization, this paper reviews the research literature on ER use to examine what is known about factors that influence three stages of the help-seeking process: (1) problem recognition; (2) the decision to seek help; (3) the decision to use the ER. While predisposing factors other than race are not generally significant, enabling factors such as income, insurance coverage, having a usual source of care, and geographic proximity affect use of the ER, both alone and in interaction with race and other factors. The most common reason for non-urgent ER use was 'other care not available'. In addition to the absence of primary care, non-urgent use of the ER is linked to need factors arising from socioeconomic stress, psychiatric co-morbidities, and a lack of social support. Recommendations for future studies include examining prospectively all 3 stages of decision-making leading to ER use, and considering interactive effects among predictors. Implications for service delivery are discussed, including the need to re-structure health care delivery systems to provide greater access to primary care and provide more attention to psychosocial aspects of patient care in clinical settings.

Emergency department utilization: a comparative analysis of older-adults, old and old-old patients

A comparative analysis of Emergency Department (ED) utilization by 2936 older-adults, old, and old-old patients was conducted in the only hospital available for residents of a vast geographical region. All patients (45+) who arrived at the ED during the first week of every even month from September 1986 to August 1987 were selected for the study. No significant differences were found among the three groups with regard to sociodemographic characteristics other than age. Data showed that the old-old use the ED approximately twice as much as the old and the older-adults; they also use the ED more often than the two other groups during the winter season. These two findings indicate the utility of viewing the old-old not only as a part of the elderly population, but also as a unique risk group. Hospitalization rates present a different pattern: they double in each age group moving from the youngest to the oldest. Complaints of an internal medicine nature are more often presented by the two groups of the elderly in comparison to the older-adults, and are followed by more frequent hospitalizations in internal medicine wards. Such findings have practical implications, and should be taken into consideration by policymakers.

Correlates of emergency room utilization in the first year of life

We conducted a case-control study to examine the correlates of emergency room use in the first year of life, particularly the role of parental health beliefs, among the families of inner-city children enrolled in a hospital-based primary care program. Data was collected by structured interviews and by medical record review. Emergency room users were more likely to have single mothers and to have acute, recurrent medical conditions than were non-users. Health beliefs differed between groups by maternal report of worry about the kinds of illnesses that her child acquires. Emergency room use was predicted by: maternal marital status, maternal worry and concern that illness interferes with her child's activity, acute recurrent illnesses, hospitalization. This model may be applicable to other populations in designing intervention strategies to modify emergency room utilization.

Emergency department utilization by two subcultures in the same geographical region

An exploratory study of emergency department (ED) utilization, comparing Israeli adult Jews and Bedouin Arabs was conducted. The data interpretation derived from the premise that health services utilization reflects not only morbidity patterns but characteristics of both subcultures and the structure of health services. The Bedouins in the study are a Moslem traditional society going through a rapid process of urbanization and modernization, with a relative deficiency in primary health services. Data were collected from the general ED admissions registry. Patients (17+) who arrived at the ED during the first week of every even month of one calendar year were selected for this study (6815 Jews and 583 Bedouins). The findings indicate that, in general Bedouins use the ED significantly less than Jews. They adjust to the structure of the ED services and use them, more than Jews, as a primary service. Yet, the hospitalization rates of the two populations are similar. In both subcultures the pattern of gender differences changes after the age of 45. The change, however, is in the opposite direction. Differences in ED usage among Bedouin age-sex groups are discussed in terms of changes in social status during a period of socio-cultural transition.

An ecological study of the relationship between risk indicators for social disintegration and use of a somatic emergency department

During the last decade a number of studies have been dedicated to the relationship between social support and ill health. In this study the relationship between risk indicators for social disintegration in defined geographical areas and the utilization of a hospital somatic Emergency Department (ED) by the inhabitants of these areas was analyzed. Six socio-demographic variables were used as risk indicators for social disintegration. To measure illness behaviour a register of 57,481 ED visits, made by 34,915 individuals, to the General Adult ED at St Göran's Hospital was utilized. The proportions of immigrants, of adult unemployed and of persons moving into the areas were significantly related to the illness behaviour of seeking care at the ED. The results also showed a significant correlation between the sum of the six risk indicators and use of ED services for three of the four studied subgroups.

Heavy users of an emergency department--a two year follow-up study

Persons who repeatedly turn to emergency departments (ED) for medical services often have an unfavourable social situation. Very little is known about how their situation and utilization of ED services change with time. In the present study, 232 persons who had made 4+ visits to an ED during the previous year were followed for two years. In the first year 31% and in the second 19% of the original group remained heavy users of the ED. Patients diagnosed as having bronchial asthma remained heavy ED users to a greater extent than others. The mortality in the whole group was high, the standardized mortality rate (SMR) was 590% for the men and 740% for the women during the first follow-up year and 380% respectively 350% during the second. A sub-sample of the patients was interviewed both in the beginning and at the end of the study period with regard to psycho-social factors. The follow-up analysis showed that number of previous visits, contact with psychiatric care, living alone and perceived loneliness were predictive factors for continued ED use. Twenty-two percent of the variation in ED use could be accounted for by changes in the social network over time. The present study supports the hypothesis that the quality of the social network is related to the use of medical services, here expressed in ED use. The findings raise the question of how to handle the variety of psycho-social problems found among these ED users.

Patients who leave a pediatric emergency department without treatment

We describe a population of 296 patients (1.1% of 27,230 pediatric emergency department visits) who left a pediatric ED without treatment during a 12-month period. Most occurred on weekends (n = 120; 41%), registered between 4 PM and midnight (n = 174; 59%), were on public aid (n = 161; 54%), had no known source of health care (n = 188; 64%), and waited less than three hours before leaving (n = 187; 63%). Most were not seriously ill; 12 children (4%) had urgent or emergency problems. Minor trauma was the most common reason for the visit. Two hundred twenty-three (75%) were contacted by telephone two days later. A long waiting time was the most commonly cited reason for leaving (137/231; 59%). One hundred sixteen patients (52%) did not seek other medical care; 36 (16%) went to another hospital ED. Forty-eight hours after leaving without treatment, 112 patients (50%) were well, 65 (29%) had improved, 34 (15%) were unchanged, two (less than 1%) were worse, and seven (3%) had been hospitalized.

The impact of the family and lay others on care-seeking during life-threatening episodes of suspected coronary artery disease

To understand the impact of the family on care-seeking during a suspected episode of acute coronary artery disease (CAD) interviews were conducted with 1102 individuals hospitalized for a suspected myocardial infarction. Analyzing the care-seeking behavior of these individuals within life threatening illness behavior and situational perspectives, bivariate and multivariate analyses revealed that family members, especially a spouse, had both positive and negative influences on the duration of time between acute symptom onset and arrival at a hospital emergency room. To reduce both the morbid and mortal consequences of acute CAD it is recommended that we direct our intervention efforts toward warning the public of situational circumstances which contribute to extended self treatment and evaluation during acute episodes of CAD.

Hospital-sponsored medical groups: their impact on access to primary care in rural communities

Rural communities have traditionally been underserved in terms of the availability of primary medical care services and providers. The Robert Wood Johnson Foundation launched a major program in the mid-1970s to improve the delivery of primary care to previously underserved rural, small town, inner city and other urban communities through their Community Hospital Program (CHP). This program provided grant funds to over 50 community hospitals throughout the country to develop primary care-oriented group practices. Twelve of the 53 programs eventually funded were sampled for a national evaluation of the impact of the CHP groups on access to care in the communities they served. The analyses reported here summarize the access impact of this innovation on the four rural and small town communities included in the larger evaluation. Baseline surveys in these four communities established that, in general, access was poorer in the rural areas, in particular, compared to the national average. The new groups tended to attract a cross-section of the communities they served. In general, they tended to do as well or better as other sources of care in the area in providing access to care. The most successful groups were those that most closely mirrored the traditional private practitioner--"family doctor"--model of care.

Inappropriate emergency department visits

Guidelines adopted in 1982 by the American College of Emergency Physicians were used to determine appropriate and inappropriate emergency department (ED) utilization patterns at three community hospitals during a two-week period in August 1983. In all, 3,130 visits were examined. There was an overall inappropriate visit rate of 10.8%, although considerable variation was observed among the three hospitals. Subgroups with the highest inappropriate visit rates included the following: 1) persons with Medicaid as the primary payment source (17.3%); 2) children aged 5 years or younger (15.2%); 3) those unable to identify a personal physician (14.1%); 4) unemployed persons (13.1%); 5) patients making visits during regular office hours (12.6%); and 6) those failing to attempt to contact their personal physicians (12.4%). These variations in inappropriate usage were all statistically significant at the P less than .05 level or better. Inability to identify a personal physician emerged as the most pervasive influence on inappropriate ED visit rates (P less than .001).

Hospital care utilization in a 17,000 population sample: 5-year follow-up

The growing utilization of hospital care, especially of the services of Emergency Departments (ED), has been of great concern for many Western countries. The purpose of this study was to relate the amount of hospital care utilization to the frequency of ED visits. The study, based on a computerized medical information system, was carried out at Huddinge hospital which serves a suburban area of Stockholm, Sweden. ED visits were found to predict hospital care utilization in a 5-year follow-up of a 10% population sample. Persons who had made 2 or more ED visits during a period of 15 months before follow-up (less than 1/8 of the population sample) contributed 24% of all hospital outpatient visits, 29% of all hospital admissions and 31% of all hospital days during the 5-year follow-up period. The number of hospital outpatient visits per 100 personyears was more than 3 times higher among those who had 4 or more ED visits as compared to those who were non-visitors at the ED. Hospital admissions and days were 5 times higher. The utilization of medical specialties differed most in psychiatry, where those with 4 or more ED visits had nearly 17 times more admissions per 100 personyears than non-visitors. The difference increased gradually with increasing number of ED visits and was also evident in each age group. The mortality was also significantly increased for those with several ED visits. Higher migration in the latter group may besides indicate social instability.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency room leavers: a demographic and interview profile

Emergency rooms are used frequently by patients who do not require urgent treatment. Furthermore, a small but sizable number of these patients in busy emergency rooms leave (walk out) before they are actually examined by medical personnel. Data were analyzed for all patients presenting to a university-affiliated hospital emergency room during a one-year period. Six hundred forty-four persons left the emergency room before being seen (leavers). Based on a code routinely assigned to their presenting complaint, patients were divided into urgent and nonurgent categories. A random sample of 100 leavers was matched with nonurgent stayers by age, sex, race, and shift of presentation. Information was collected from medical records and telephone interviews. A multiple discriminant analysis revealed the following profile of the leaver: a person who lives within 21/2 miles of the hospital has either Medicare/caid or no medical insurance, has no private physician, and has a nonserious presenting complaint. Stayers, on the other hand, have more serious complaints, tend to have medical insurance, more often have a private physician, and may live at any distance from the hospital. In addition, leavers presented with drug, alcohol, or psychiatric problems more frequently than stayers. Leavers, on the average, spend 90 minutes waiting for treatment they never receive. This study characterizes a small but problematic subgroup for emergency department planners and suggests the need for community-based health education and referral of such patients to primary care centers.

Neighborhood variations in the use of hospital emergency rooms for primary care

The purpose of the paper is to analyze neighborhood variations in the use of emergency rooms (ERs) as settings for primary care within Oklahoma County, part of the Oklahoma City MSA. The location of patients taken from a sample of ER records in four large hospitals were aggregated to census tracts. Tract visitation rates were estimated and related to the socio-economic character and the relative location of the tracts for two periods--'physicians' office hours' and 'non-office hours'. The results show that for the city as a whole primary care use in emergency rooms is associated with the socio-economic status and relative location of a residential area. Tracts with lower socio-economic status have higher rates of emergency rooms use for primary care than those of higher status. This relationship is true both during physicians' office hours as well as during the times their offices are closed. When visitation rates are analyzed separately for individual hospitals, location rather than neighborhood socio-economic characteristics is paramount. It was concluded that while primary care visits to emergency rooms are higher in lower socio-economic status neighborhoods, and that this is a function of the more accessible location of emergency rooms to these neighborhoods as well as to socio-economic effects on use.

Free-standing emergency clinics: community development guidelines

When a free-standing emergency clinic (FEC) unexpectedly opened in Montgomery County, Maryland, the local emergency medical services council thought the FEC's operational plan was in conflict with the community concept of emergency medical services (EMS). Because there were no agreed upon factual guidelines with which to judge the FEC, the council established a task force to study the problem and to develop standards and guidelines. This article is based on that report. We recommend that if a facility physically separate from a hospital uses the words "emergency" in offering medical services, it means at least 24 hours of operation with standards at least equal to those offered by the local EMS system.

The hospital emergency department as the primary source of medical care

The role of hospital emergency departments has gradually changed, particularly in large urban areas, where these departments have increasingly become outpatient clinics for everyday ailments rather than centres for the treatment of injuries and emergencies. The main objectives for the present study were: (1) to compare the utilization of district general practitioners and the hospital emergency department by a defined population; (2) estimate how many of the visits to the hospital emergency department are general practitioner-type visits. The results demonstrate the pattern of medical care usage in an area with hospital emergency department services which provide a 24-hour availability and open access, while the primary care services are available only during office hours, are understaffed and have limited access. The study is based pm a 1/30 sample (1032 individuals) from the population in the catchment area of a health centre in Stockholm. During the study period (15 months) 30% of the population visited the hospital emergency department, while 15% consulted district general practitioners. Of the visits to the hospital emergency department, 17 per cent were for injuries and between 39 and 64% were general practice-type visits, according to the criteria used in the study.

Nonemergency visits to a pediatric emergency department

We examined six factors that may help to explain why parents take their children to hospital emergency departments: arrival time; travel time; who decided the patient should go; did the patient have a physician; did the parent attempt physician contact, and where the parent would have preferred to have gone for treatment. Results indicate that 47% of the nonemergency visits occurred during the time when physicians maintain office hours. Most visits were made by patients living less than 15 minutes away from the hospital. Physicians decided that the patient should go to the emergency department 18% of the time. Patients with a private physician accounted for 80% of the visits. Most parents did not try to contact a physician prior to the visit. Indeed, 46% of the parents preferred to take their children to the emergency department rather than to a physician's office. Finally, 74% of the parents who attempted some contact with a member of the health care system were referred to the emergengy department for care.