Can nonurgent emergency department use be reduced? Empirical evidence from a nationally representative sample

Objective:

A well-functioning primary care system will have the capacity to provide timely, adequate, and effective care for patients to avoid nonurgent emergency department (ED) use. This study examined how access to and quality of ambulatory care is associated with nonurgent ED use nationwide.

 

Methods:

This retrospective cohort study used the 2010-2011 Medical Expenditure Panel Survey data, where individuals aged 18 and older with complete data for all five rounds were selected. This study chose a usual source of care status, perceived convenience to get medical care, and patient evaluation of care quality as the main independent variables that measure access to and quality of ambulatory care.

ED use urgency was determined based on modifications of literature criteria. The multivariate logit model was employed to analyze the urgent vs. nonurgent ED use in 2011, after controlling for age, sex, race, insurance, and rural vs. urban residence in 2010. All predictors were treated as dummy variables.

The lagged time effect was employed to account for the engogeneity between outcomes and predictors. The weights and variance were adjusted using the survey procedures.  

Results:

The final study sample consisted of 1,287 adults with at least one ED visit in 2011, which represented a weighted 29,463,684 people in the total population. Among them, 390 individuals (30.3%) had nonurgent ED use, representing a weighted 8.3 million people nationwide.

In the multivariate logit model, while a usual source of care status and perceived convenience to get medical care were not associated with nonurgent ED use (both at p > 0.05), patient perceived better primary care quality had lower odds of a nonurgent ED visit (OR=0.42, p=0.026), with a marginal effect (at means) of 11.9% lower predicted probability of nonurgent ED use. In addition, non-Hispanic white and black individuals compared with other races also had lower odds of a nonurgent ED visit (both at p < 0.05), with a marginal effect of 24.8% and 17.9% lower predicted probability, respectively.

Conclusions:

Patients’ perceived primary care quality played an important role in their decision of nonurgent ED use, while access to ambulatory care did not.

These findings highlight the target areas and inform policies of effective strategies in reducing nonurgent ED use. Without improving ambulatory care quality, endeavors simply aiming to encourage the use of outpatient clinics, to increase primary care supply, or to increase ED cost sharing levels may not be effective in improving healthcare system efficiency.