Barriers to outpatient care resulting in increased emergency department utilization

Background: While the Emergency Department (ED) serves as a safety net for the uninsured and medically under-served, those patients with primary and specialty care physicians also seek potentially non-emergent care through the ED.
Specific Aims: This study serves to elucidate the medical decision making of those patients presenting to the ED for non-emergent medical care.
Methods: A single round, cross-sectional, categorical and Likert scale survey was administered to a sample of ambulatory, non-urgent adult patients presenting through triage at an urban, tertiary care teaching hospital and Level 1 Trauma Center with an annual census of 63,000, over a four month period. Any patient with an Emergency Severity Index (ESI) of 1 or 2 and those arriving via EMS were excluded. Data were analyzed using logistic regression.
Results: A total of 274 patients were enrolled, 39% male and 61% female with an average age of 42.1 years. 219 (80%) reported having health insurance. 200 (73%) had a primary care physician and 41% had additional specialty care. 63% presented to the ED between 9am-5pm, while the rest presented equally between 5pm-1am and 1am-9am (19% and 18%, respectively). Only 23% called their doctor’s office before coming to the ED; of these, 75% were advised to go to the ED. While 85% would prefer to see their doctor if they were offered a same day appointment, 48% reported the main barrier to seeing their doctor was difficulty scheduling an appointment. Factors associated with not calling a doctor’s office were: presentation to the ED outside regular office hours (p = 0.009), shorter duration of symptoms (p = 0.003), and reporting convenience and ease as important factors in the decision to come to the ED (p = 0.012). Significant predictors of high ED utilization (> 3 visits within 12 months) were a previous visit to the ED for the same problem (p = 0.002) and the opportunity to have tests, treatments, and diagnosis at the same place as an important factor in medical decision-making (p = 0.044).
Conclusion: This study highlights specific barriers in access to outpatient medical services other than health insurance coverage or having a PCP. A patient centered approach of systems-based changes in primary and specialty care access, specifically in appointment scheduling, could help to reduce potentially unwarranted health services from the Emergency Department.