Administration of Emergency Medicine
Patient Motivators for Emergency Department Utilization: A Pilot Cross-Sectional Survey of Uninsured Admitted Patients at a University Teaching Hospital

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Abstract

Background

During the past several decades, emergency department (ED) increasing volume has proven to be a difficult challenge to address. With the advent of the Affordable Care Act, there is much speculation on the impact that health care coverage expansion will have on ED usage across the country. It is currently unclear what the effects of Medicaid expansion and a decreased number of uninsured patients will have on ED usage.

Objective

We sought to identify the motivators behind ED use in patients who were admitted to a university teaching hospital in order to project the possible impact of health care reform on ED utilization.

Methods

We surveyed a convenience sample of uninsured patients who presented to the ED and were subsequently admitted to the inpatient setting.

Results

Our respondents sought care in the ED primarily because they perceived their condition to be a medical emergency. Their lack of insurance and associated costs of care resulted in delays in seeking care, in reduced access, and a limited ability to manage chronic health conditions. Thus, contributing to their admission.

Conclusions

Affordability will reduce financial barriers to health care insurance coverage. However, efficient and timely access to primary care is a stronger determinant of ED usage in our sample. Health insurance coverage does not guarantee improved health care access. Patients may continue to experience significant challenges in managing chronic health conditions.

Introduction

Emergency department (ED) utilization rates have been growing rapidly in the United States, with an estimated 117 million visits in 2010 (1). Increasing ED volume is a significant challenge that prevents physicians and nurses from providing quality care to patients within a reasonable amount of time (2). Recent studies estimate that between 10% and 30% of ED visits are for nonurgent conditions (3). Such ED utilization has been attributed to barriers in timely and efficient access to primary care, lack of transportation, cost of care, wait times, and opening hours 4, 5, 6, 7, 8, 9. Some studies suggest that patients insured through the Affordable Care Act (ACA) will increase ED utilization rates 10, 11.

The ACA is significantly reducing the number of uninsured patients through the expansion of Medicaid and health insurance exchanges. Medicaid eligibility and subsidized insurance may mitigate the financial barriers that contribute to increased ED use (12). However, this does not address other barriers to timely and efficient access to primary care, particularly the community-level barriers. Cheung et al. observed a direct relationship between the number of barriers faced by Medicaid recipients and ED use (8). In addition, a study by Lowe et al. indicated that community characteristics play a significant role in the decision to seek care in the ED (5). However, the attitude, behavior, and decision making of the previously uninsured will play a significant role on health care utilization patterns.

We set out, before the implementation of the ACA, to survey uninsured patients visiting the ED about their health care choices and health care utilization decisions. We sought to identify the motives for which uninsured patients sought care in the ED and project whether these would promote ED use under the ACA. We hypothesized that the ED visits in these patients were prompted primarily by emergencies, and not to fulfill primary care needs. Our ultimate goal was to describe the characteristics of a convenience sample of uninsured patients admitted to the ED at a university hospital, the impact of the lack of health insurance on their health status, and identify motivators for seeking care in the ED over of a primary care provider.

Section snippets

Materials and Methods

The university teaching hospital is located in a large urban setting and provides services to inhabitants of the surrounding areas. It is the only Level I trauma center in Orange County and handles nearly 48,000 patient visits during the course of the year. We performed a descriptive, pilot cross-sectional survey administered to patients admitted to the inpatient setting through the ED between mid-July and mid-August of 2012. During this time period, medicine service case managers identified

Results

We approached 51 patients admitted to the medicine unit of the university teaching hospital. Fifty patients agreed to participate in the study and completed the survey. One participant declined. The demographics of the respondents are shown on Table 1. Mean age of the respondents was 47 years, 60% were male, respondents were predominantly Latino (62%) and Caucasian (26%), and 16 (32%) were undocumented immigrants. They resided predominantly in North Orange County (88%).

Discussion

Although our data might not generalizable to the entire population, our survey revealed some important themes in health care utilization, which can be used as areas of analysis in future studies attempting to address the effects of the ACA.

Our study suggests that admitted uninsured patients seek care in the ED primarily because of the perceived urgency of their conditions and, less commonly, for geographic convenience, lack of health care coverage, or timely access to care. However, they

Conclusions

ED use among the patient sample we interviewed was driven by a perception of medical urgency, rather than by economic or convenience motives. Medical complications in this sample were attributed to delays in seeking care and lack of timely access to primary care. The provision of affordable health insurance options made available by the ACA will increase patient health insurance coverage. However, it is unclear whether increased health care coverage will actually translate to increased access

Acknowledgments

The authors are grateful for the contribution of the case managers: Cynthia Beck, Jane Jordan, Debbie Mansueto, Pamela Marks, and Ann Nolan. We would also like to thank the Orange County Health Needs Assessment Organization and to the authors of the HOLA mentee survey for allowing us to use some of their survey questions as part of our questionnaire. The University of California, Irvine School of Medicine Dean’s Office provided a summer research grant that contributed to the data collection for

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    K. Lozano and U. C. Ogbu contributed equally to this work.

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