File Name: nonurgent emergency department patient characteristics and barriers to primary care .zip
In recent years, there has been an increased utilization of emergency departments EDs in many countries. Additionally, it is reported that there are major delays in delivering care to ED patients.
- Nonurgent patients in the emergency department? A French formula to prevent misuse
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- Nonurgent patients in the emergency department? A French formula to prevent misuse
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Percentage of population reporting emergency department use by barrier to timely primary care access. Arch Intern Med. This can lead patients to use the emergency department ED as a ready alternative to their usual source of medical care, even when such care could be provided more cost-effectively in a primary care setting.
Nonurgent patients in the emergency department? A French formula to prevent misuse
Percentage of population reporting emergency department use by barrier to timely primary care access. Arch Intern Med. This can lead patients to use the emergency department ED as a ready alternative to their usual source of medical care, even when such care could be provided more cost-effectively in a primary care setting. The purpose of this study was to examine the relationship between ED visits and perceived barriers to receiving timely primary care.
Associations between perceived timely access barriers and reported use of ED in the previous 12 months were examined using logistic regression to control for covariates that also affect ED use. For those reporting 1 or more barriers, the proportion having an ED visit was 1 in 3. Interventions to improve effective access to medical care such as open access scheduling might have benefits not only for individual patients and practices but also for health policy related to cost-effective health care delivery systems and our need to relieve overcrowded conditions at EDs.
Emergency department ED crowding is a significant problem in the United States. The number of ED visits rose from Aside from issues of overcrowding, inappropriate use of EDs for nonemergency conditions may also lead to less effective preventive care and chronic disease management, and even higher health care costs, although there is significant debate about how precisely to measure the appropriateness of any particular visit.
Promoting access to high-continuity primary care is therefore important not only as a potential strategy for reducing unnecessary ED utilization but also as an essential strategy for improving chronic disease care and outcomes. Simply being able to name a usual source of medical care is not the same as having effective and timely access to that same source of care. Some small or local studies have suggested that barriers to timely access of primary care might lead patients to seek care in the ED as an accessible alternative.
In a study that focused on Medicaid patients, Lowe et al 10 found that modifiable access characteristics of primary care practices such as longer evening hours and a lower ratio of the number of active patients per clinician-hour of practice time were indeed associated with less ED use.
Sarver et al 11 attempted to evaluate this issue in using national data from the cohort of the Medical Expenditure Panel Survey MEPS and found that these barriers were associated with ED visits for nonurgent conditions, but the associations were not significant in multivariate analysis.
Therefore, we undertook this study to examine the links between ED visits and perceived barriers to receiving timely primary care. We analyzed data from the NHIS, a continuing probability survey of American households that is representative of the US civilian noninstitutionalized population.
The NHIS data are collected through a complex sample design involving stratification, clustering, and multistage sampling with a nonzero probability of selection for each person. Final sampling weights allow estimates from the NHIS to be generalized to the adult civilian population of the United States. In this study we included only persons who reported having a non-ED usual source of medical care for illness events. Of the entire survey sample, Only 0. These measures were consistent with the measures of access barriers used in previous studies.
Participants were classified as nonusers no visit and ED users 1 or more visits. We used 3 age groups: 18 to 44 years, 45 to 64 years, and 65 years or older. Educational attainment was determined by asking participants to indicate the highest level of school completed, and the responses were grouped into less than high school, high school graduate, and higher than high school.
Participants were considered insured if they reported private insurance or public insurance; others were coded as having no insurance. Health status was based on self-reported health condition good-excellent or fair-poor.
Because the nonresponse rate was high for total family income, we reran analyses including respondents with missing income data and found no effect on the results of this study. Bivariate analyses were conducted to compare the sample's sociodemographic characteristics, health status, and reported barriers to timely medical care. Multivariate logistic regression analyses were also conducted to assess the independent association of barriers to timely medical care with the likelihood of ED use.
Data analyses and statistical tests were conducted using SPSS statistical software, version The SPSS complex analysis module was used to adjust for the complex survey design and population sampling weights. All P values are 2-tailed, and values less than.
Among all adults aged 18 to 84 years, about 1 in 5 adult Americans Among those who claimed to have a non-ED usual source of medical care, An estimated Table 1 summarizes the estimated population who reported each of the barriers to timely care.
Table 2 compares ED visitors and non-ED visitors by demographic strata and barriers to medical care. Data from bivariate analyses listed in Table 2 demonstrate substantial differences in ED use according to demographic and socioeconomic characteristics of the sample.
Women were somewhat more likely to be ED users than men As self-identified in the survey, black or African American adults were somewhat more likely than white adults Both household income and education level were related to ED visits. People with low household incomes were more likely to report an ED visit than people with higher incomes People with less than a high school degree were more likely Health status had a larger impact on ED use, with people in poorer health being more than twice as likely as those in better health to be an ED user Those who reported at least 1 barrier to timely primary care were more likely to be an ED user than those who did not report such barriers The bivariate analysis performed on specific barriers and ED use revealed that each of the 5 barriers was associated with a higher likelihood of ED visits Table 3 and Figure.
In a full multivariate model controlling for sociodemographic and health status variables, the odds ratios ORs of ED use were significantly different between people with and without barriers to getting timely medical care. There was also some overlap among persons responding affirmatively to each of the barrier questions. Among persons who answered yes to any of the barrier questions, More than 1 in 5 adults in nearly every demographic subgroup in America had at least 1 ED visit each year.
A main finding of our study is that having a regular source of primary medical care may be necessary but not sufficient to lower the risk of ED use. Barriers to timely access appear also to be highly associated with the risk of using the ED in the past year. This relationship persists even after adjusting for socioeconomic and health-related factors. Our findings suggest that patients are more likely to use the ED when there are barriers that keep them from getting timely medical care.
Even though all subjects in our data set reported having a regular source for medical care when sick, various problems with accessing medical care such as long waiting times in the physician's office, limited availability of appointments, or difficulty getting through to the physician on the telephone may still increase their tendency to use the ED. This result is consistent with the findings of previous studies that examined the links between specific aspects of primary care and ED use.
For example, Bair et al 13 demonstrated that patients with asthma who reported at least 1 problem accessing medical care were more likely to have made at least 1 asthma-related ED visit. Similarly, Fredrickson et al 14 found that parents of patients with asthma who used the ED would have greatly preferred to use primary care but faced substantial barriers.
Some studies have shown that having a primary care physician as the usual source of care can decrease use of the ED, 15 while other studies have shown that frequent users of the ED are also frequent users of other medical care, including primary care, in part owing to the severity of their illness or comorbidity. Our findings from the NHIS 12 may help explain the conflicting results of previous studies regarding the relationship between access to primary care and ED use.
The numbers of patients reporting various access barriers in NHIS 12 also generally reinforce the conclusions of a Commonwealth Fund survey 19 that compared adult health care experiences in 7 countries.
Our analysis suggests that providing primary care access is necessary but not sufficient for reducing unnecessary visits to the ED. Availability and potential access are not the same as real-world, timely, and effective access to care.
According to Starfield, 20 good primary care is characterized by high levels of first-contact accessibility, patient-focused care over time, a comprehensive package of services, and coordination of services when services are required elsewhere. When any of these qualities are missing, patients may not be able to obtain timely medical care from their usual care source and may have to resort to the ED for those services. Only lack of transportation might be considered primarily a patient-level barrier.
Answering the telephone on time, being available for appointments, and other important behavior might be amenable to various forms of practice reengineering or quality improvement.
Open-access scheduling is an intervention that has been demonstrated to increase patient satisfaction and the perception of accessibility and improve practice efficiency and continuity of care.
One limitation of this study is that it relied on self-reported ED use rather than a direct measure of ED visits or claims. We also were able to assess ED use only in general rather than differentiating between emergency care— vs primary care—related ED use or between visits for ambulatory care sensitive conditions ACSC vs visits for non-ACSC conditions.
Although many medical problems can be cared for in alternative settings, many ED visits result from true emergencies.
Still, our ability to differentiate between what could and could not be cared for in a primary care setting is limited, especially in self-reported survey data. Another limitation is that health status is a driver of ED use and might confound our results, given the limited information on specific medical conditions and severity of illness available in the NHIS.
In addition, as some studies have pointed out, the survey techniques of the NHIS 12 may have missed vulnerable populations such as homeless subjects or undocumented immigrants.
Self-reports of having a usual source of medical care may also overstate respondents' actual connection to a primary care medical home. However, the NHIS oversamples minority populations and includes significant numbers of individuals whose socioeconomic status is below poverty level.
It is also the survey with a sampling frame explicitly designed to be generalizable to the entire US civilian, noninstitutionalized population. We conclude that timely access to primary care may be more relevant to ED use than is the simple ability to name a usual source of medical care. The present study identifies specific, potentially fixable barriers to primary care access such as inability to get through to the physician by telephone or to get a timely appointment for acute illness episodes.
Timely access barriers to primary care create excess ED visit risk for all adults and even greater risk for the uninsured and for those whose health status is poor. Author Contributions: Drs Rust and Ye had full access to all of the data in the study and take full responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design : Rust and Ye. Acquisition of data : Ye. Critical revision of the manuscript for important intellectual content : Rust, Ye, Baltrus, Daniels, Adesunloye, and Fryer. Statistical analysis : Ye, Baltrus, and Fryer.
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Inappropriate use of emergency services: a systematic review of prevalence and associated factors. This systematic review aimed to measure the prevalence of inappropriate emergency department ED use by adults and associated factors. The review included 31 articles published in the last 12 years. Female patients, those without co-morbidities, without a regular physician, without a regular source of care, and those not referred to the ED by a physician also showed more inappropriate ED use, with the relative risk varying from 1. Difficulties in accessing primary health care difficulties in setting appointments, longer waiting periods, and short business hours at the primary health care service were also associated with inappropriate ED use. Thus, primary care requires fully qualified patient reception and efficient triage to promptly attend cases that cannot wait. It is also necessary to orient the population on situations in which they should go to the ED and on the disadvantages of consulting the ED when the case is not really urgent.
The pressures of patient demand on emergency departments EDs continue to be reported worldwide, with an associated negative impact on ED crowding and waiting times. It has also been reported that a proportion of attendances to EDs in different international systems could be managed in settings such as primary care. This study used routine ED data to define, measure and profile non-urgent ED attendances that were suitable for management in alternative, non-emergency settings. A validated process based definition of non-urgent attendance was refined for this study and applied to the data. Using summary statistics non-urgent attenders were examined by variables hypothesised to influence them as follows: age at arrival, time of day and day of week and mode of arrival.
Reducing non-urgent emergency department ED visits has been targeted as a method to produce cost savings. To better describe these visits, we sought to compare resource utilization of ED visits characterized as non-urgent at triage to immediate, emergent, or urgent IEU visits. We performed a retrospective, cross-sectional analysis of the — National Hospital Ambulatory Medical Care Survey. Urgency of visits was categorized using the assigned 5-level triage acuity score. We analyzed resource utilization, including diagnostic testing, treatment, and hospitalization within each acuity categorization. From —,
Article Information, PDF download for Primary Care Access Barriers as Reported Among a sample of nonurgent ED users, what are patient-reported barriers to characteristics, primary care infrastructure/organization, ED.
Nonurgent patients in the emergency department? A French formula to prevent misuse
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