Uninsured Trauma Patients More Likely to Visit Emergency Departments Than Outpatient Clinics

Providing access to an outpatient clinic is not enough to keep some trauma patients who have been discharged from the hospital from returning to the emergency department (ED) for follow-up care, even for such minor needs as pain medication refills and dressing changes, according to new Johns Hopkins research.

Reporting in the Annals of Emergency Medicine, the researchers say that patients with Medicaid, Medicare and those with no insurance were 60% more likely to seek such care in the ED. Those living in poor neighborhoods were 70% more likely than patients with insurance to head to the ED instead of going to a doctor’s office or clinic.

The findings suggest that, for reasons that are not well understood, many patients who could receive less expensive outpatient care will not or can not seek it, according to the Hopkins research team. These patients, the researchers suggested, end up receiving far more costly care in the ED, where they have longer waits and add to the crowding that burdens many emergency rooms.

“Just providing patients access to doctors outside of the ER clearly isn’t working, especially for those without insurance,” Adil H. Haider, MD, MPH, an assistant professor of surgery at the Johns Hopkins University School of Medicine and study leader, said in a press release. “We need better ways to help patients discharged from the hospital receive appropriate follow-up care.”

Haider and colleagues analyzed the records of 6,675 trauma patients admitted to The Johns Hopkins Hospital between 1997 and 2007. Roughly 13% of these patients returned to the ED within a month of discharge, yet nearly 90% of them were not readmitted into the hospital, suggesting that their ER visit was avoidable and that they could have been treated in an outpatient clinic, according to Haider. Among the small number of return patients who were readmitted, the main cause was complications from their original injury and hospitalization.

Along with being uninsured or government insured and living in low-income neighborhoods, black patients and those with more serious injuries were more likely to return to the ED for follow-up care. Patients who were discharged to a rehabilitation, nursing or acute-care facility were significantly less likely to return to the ER than those who were discharged home. The nature of the injury made no difference, the researchers found.

All trauma patients discharged from Johns Hopkins received a free follow-up appointment, regardless of insurance. Therefore, access to care should not be an issue even for those who have no insurance and are too poor to afford private care, the investigators suggest.

“Clearly, there are more factors at play than just having an appointment or access to care,” Haider said.

One possible factor, the researchers added, might be that clinic appointment times are inconvenient for those who cannot take time off work or who have no transportation.

“Regardless of the underlying cause, further research is needed to investigate how the system can be more efficient in taking care of these vulnerable populations,” Haider stated. “Improving follow-up care for these vulnerable patients will not only improve the quality of their care, but will also ease the burden on already strained emergency departments and reduce overall healthcare costs.”

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