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Impact on Adult Use of Emergency Department Services

George Rust, MD, MPH; Jiali Ye, PhD; Peter Baltrus, PhD; Elvan Daniels, MD; Bamidele Adesunloye, MD; George Edward Fryer, PhD

Arch Intern Med. 2008;168(15):1705-1710.

Background  Most Americans report having a usual source of medical care, but many also report significant barriers to timely access to such care. 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.

Methods  Among 30 677 adults 18 years or older participating in the adult sample section of the National Health Interview Survey, 23 413 who reported having a usual source of medical care other than the ED and answered the questions related to barriers were included in our analyses. 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.

Results  For those reporting no access barriers, 1 in 5 adult Americans in the noninstitutionalized civilian population visited an ED at least once during the preceding year. For those reporting 1 or more barriers, the proportion having an ED visit was 1 in 3. Four of the 5 following timely access barriers was independently associated with ED use, even after adjusting for other socioeconomic and health-related factors: (1) "couldn't get through on phone" (OR [odds ratio], 1.27; 95% confidence interval [CI], 1.02-1.59); (2) "couldn't get appointment soon enough" (OR, 1.45; 95% CI, 1.21-1.75); (3) "waiting too long in doctor's office" (OR, 1.20; 95% CI, 1.02-1.41); (4) "not open when you could go" (OR, 1.24; 95% CI, 0.99-1.55); and (5) "no transportation" (OR, 1.88; 95% CI, 1.50-2.35).

Conclusions  The benefits of having a usual source of medical care are diminished by barriers that limit effective and timely access to such care. 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.

Author Affiliations: National Center for Primary Care (Drs Rust, Ye, Baltrus, and Daniels) and Department of Internal Medicine (Dr Adesunloye), Morehouse School of Medicine, Atlanta, Georgia; and Department of Pediatrics, New York University, New York, New York (Dr Fryer).