Contrary to popular belief, communities with high levels of uninsured, Hispanic or immigrant residents generally have much lower rates of per person hospital emergency department (ED) use than other communities, according to a study by the Center for Studying Health System Change (HSC) published today as a Web Exclusive in the journal Health Affairs.
The study found that ED use in 12 nationally representative communities varied considerably from the national average of 32 ED visits per 100 persons in 2003, ranging from a high of about 40 ED visits per 100 people in Cleveland to a low of 21 ED visits per 100 people in Orange County, Calif.
Despite common perceptions that high rates of uninsured and immigrant residents contribute to higher ED use, communities with the highest levels of ED use generally did not have the highest numbers of uninsured, low-income, racial/ethnic minorities or immigrant residents. For example, Cleveland — where ED use was high — had low rates of uninsured and noncitizen residents, with 7.9 percent uninsured and 3.2 percent noncitizens. In contrast, Orange County — where ED use was low — had high rates of uninsured and immigrant residents, with 18.2 percent uninsured and 15.6 percent noncitizens.
"The findings are surprising and make it clear that reducing emergency department use defies simple solutions such as restricting access for noncitizens or expanding insurance coverage," said study author Peter J. Cunningham, a senior fellow at HSC, a nonpartisan policy research organization funded principally by The Robert Wood Johnson Foundation (RWJF). The study was funded by the WellPoint Foundation with support from RWJF.
Cunningham also noted that while a rapid influx of immigrants may contribute to ED crowding in some individual hospitals — particularly along the U.S.-Mexico border — immigration is not a major contributing factor to ED crowding nationally, even in many communities that have a large population of Hispanic immigrants.
"Hispanic immigrants — a high proportion of whom are uninsured — are not heavy users of EDs compared to other individuals, including whites with private insurance," Cunningham said. "And their numbers are still too small in the vast majority of communities nationwide to have a major impact on the health care system in those communities."
For example, noncitizens in 2003 on average had about 17 fewer ED visits per 100 people than citizens, while uninsured people had 16 fewer visits on average than Medicaid patients, about 20 fewer visits than Medicare beneficiaries and roughly the same rates as privately insured people.
The Health Affairs article, titled "What Accounts for Differences in Use of Hospital Emergency Departments Across U.S. Communities?," is based on HSC´s nationally representative 2003 household survey, which includes information on about 46,600 people. The study also linked secondary data sources to the communities studied, including the American Hospital Association Annual Survey, the HSC physician survey and the Health Resources and Services Administration Uniform Data System.
Along with an in-depth look at ED use in the 12 communities, which also included Boston; Greenville, S.C.; Little Rock, Ark.; Syracuse, N.Y.; Indianapolis; Seattle; Lansing, Mich.; northern New Jersey; Miami; and Phoenix, the study found similar ED use patterns in the 60 communities included in HSC´s household survey. Other key study findings include:
* Outpatient capacity constraints contributed to high levels of emergency department use in some communities as reflected by longer waits for physician appointments.
* Greater enrollment in health maintenance organizations (HMOs) and greater availability of community health centers (CHCs) were associated with lower levels of ED use, particularly for lower-income people.
* Despite the large number of population and health system factors that contribute to ED use, differences in these characteristics explain only about 40 percent of the variation in ED use between high- and low-use communities.
The study concluded that much of the variation in ED use across communities is not explained by differences in population and health system characteristics, suggesting that high emergency department use in part reflects patient preference for using emergency departments, regardless of income and insurance status, as well as practice patterns among physicians and other providers that favor greater use of emergency departments.