Reasons We Use (or Don’t Use) Emergency Departments

Consider these stories:

• A 50-year-old man slips on the ice and breaks a hip;
• A mother discovers that her 3-year old son has an escalating fever at 2 a.m.;
• A 30-year-old homeless woman complains of a sore throat and swollen glands.

OK, so these scenarios are pretty unremarkable. But their common characteristic (besides being collected from family and friends) is that each of these individuals received treatment for their respective conditions at hospital emergency departments (ED).

Now consider these questions:

• Was each visit for a medical emergency?
• Was it avoidable?
• Could the three people have been treated at another venue (such as a primary care office?)
• Where would you draw the line at what is appropriate or inappropriate use of the ED?

These questions are not as easy as they may seem. It turns out that the reasons Coloradans report for visiting an ED are complicated and traverse issues of access, coverage and perception. While EDs serve a critical function in our health care system, they are also under the microscope because they are a relatively expensive place to receive care.

On Wednesday, The Colorado Trust unveiled its most recent issue brief, An Examination of Emergency Department Use in Colorado. The brief details the results of CHI’s analysis of the 2011 Colorado Health Access Survey (CHAS). The report contains an abundance of timely findings about which Coloradans are most likely to use the ED – children, adults 65+, individuals with low family incomes, individuals covered by Medicaid and those living in urban areas, among others. The beauty of the CHAS, though, is that we not only know who is using the ED but also why.

For example, survey respondents who indicated that had gone to the ED were asked:

The last time you went to a hospital emergency room, was it for a condition that you thought could have been treated by a regular doctor if he or she had been available?

Forty-four percent of ED users answered “Yes” to this question. So does this mean that 44 percent visited the ED for a non-emergency? Probably not. How would the mother with the sick 3-year old have answered this question? Was the fever a condition that could have been treated by the family’s pediatrician if it had been 1 p.m. and an appointment was available?  Probably. Was the child in need of urgent medical attention? Yes.

Though we don’t have any diagnosis information from the CHAS, the survey does ask about common reasons people visit an ED:

• 63% of this group indicated an inability to get an appointment at the doctor’s office or clinic as soon as one was needed;
• 79% indicated needing care after normal operating hours at the doctor’s office or clinic;
• 45% indicated that it was more convenient to go to the hospital emergency room.

Thus we introduce the issue of access to care. Might the homeless woman with the sore throat have been unable to visit a community clinic due to a long waiting list? Might the doctor’s office not have accepted her Medicaid card? Might she have been unaware of safety net clinic services?

To the extent that avoidable ED usage is a symptom of greater challenges within our health care system, these questions warrant further policy focus. The analysis and other CHAS data are integral to informing ongoing discussions about new models of care, address rising health care costs, and barriers to care in the community.