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Hospital admissions through the emergency department: does insurance status matter?

  • Colin M. Sox
    Affiliations
    Department of Health Policy and Management (CMS, RAE, TAB), Harvard School of Public Health, Boston, Massachusetts, USA
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  • Helen R. Burstin
    Affiliations
    Department of Medicine (HRB, TAB), Division of General Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Department of Quality Management Service (HRB, ACO, TAB), Brigham and Women’s Hospital, Boston, Massachusetts, USA
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  • Roger A. Edwards
    Affiliations
    Department of Health Policy and Management (CMS, RAE, TAB), Harvard School of Public Health, Boston, Massachusetts, USA
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  • Anne C. O’Neil
    Affiliations
    Department of Quality Management Service (HRB, ACO, TAB), Brigham and Women’s Hospital, Boston, Massachusetts, USA
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  • Troyen A. Brennan
    Correspondence
    Requests for reprints should be addressed to Troyen A. Brennan, MD, JD, MPH, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, Massachusetts 02115
    Affiliations
    Department of Medicine (HRB, TAB), Division of General Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Department of Quality Management Service (HRB, ACO, TAB), Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Department of Health Policy and Management (CMS, RAE, TAB), Harvard School of Public Health, Boston, Massachusetts, USA
    Search for articles by this author

      Abstract

      PURPOSE: To assess the effect of insurance status on the probability of admission and subsequent health status of patients presenting to emergency departments.
      SUBJECTS AND METHODS: We performed a prospective cohort study of patients with common medical problems at five urban, academic hospital emergency departments in Boston and Cambridge, Massachusetts. The outcome measure for the study was admission to the hospital from the emergency department and functional health status at baseline and follow-up.
      RESULTS: During a 1-month period, 2,562 patients younger than 65 years of age presented with either abdominal pain (52%), chest pain (19%) or shortness of breath (29%). Of the 1,368 patients eligible for questionnaire, 1,162 (85%) completed baseline questionnaires, and of these, 964 (83%) completed telephone follow-up interviews 10 days later. Fifteen percent of patients were uninsured and 34% were admitted to the hospital from the emergency department. Uninsured patients were significantly less likely than insured patients to be admitted, both when adjusting for urgency, chief complaint, age, gender and hospital (odds ratio = 0.5, 95% confidence interval 0.3 to 0.7), and when additionally adjusting for comorbid conditions, lack of a regular physician, income, employment status, education and race (odds ratio = 0.4, 95% confidence interval 0.2 to 0.8). However, there were no differences in adjusted functional health status between admitted and nonadmitted patients by insurance status, either at baseline or at 10-day follow-up.
      CONCLUSIONS: Uninsured patients with one of three common chief complaints appear to be less frequently admitted to the hospital than are insured patients, although health status does not appear to be affected. Whether these results reflect underutilization among uninsured patients or overutilization among insured patients remains to be determined.
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      References

        • Schroeder S.A.
        Sounding board.
        NEJM. 1996; 334: 1130-1133
        • Black C.
        Strides reported on health, wage bills in Senate.
        Boston Globe. August 1, 1996;
        • Weissman J.S.
        • Epstein A.M.
        Falling through the safety net. Johns Hopkins Press, Baltimore, MD1994
        • Hafner-Eaton C.
        Physician utilization disparities between the uninsured and insured. Comparisons of the chronically ill, acutely ill, and well non-elderly populations.
        JAMA. 1993; 269: 787-792
        • Freeman H.E.
        • Blendon R.J.
        • Aiken L.H.
        • et al.
        Americans report on their access to health care.
        Health Affairs. 1987; 6: 6-18
        • Baker D.W.
        • Stevens C.D.
        • Brook R.H.
        Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department.
        JAMA. 1994; 271: 1909-1912
      1. Cong. Res. Serv. Library of Congress. Health insurance and the uninsured: background data and analysis. Washington, DC: Government Printing Office; 1988.

        • Davis K.
        • Rowland D.
        Uninsured and underserved inequities in health care in the United States.
        Milbank Mem Fund Q. 1983; 61: 149-176
        • Needleman J.
        • Arnold J.
        • Sheila J.
        • Lewin L.S.
        The health care financing system and the uninsured. Final report. Lewin ICF, HCFA Contact No. 500-89 0023, Washington, DC1990
      2. Rosenbach M. The impact of Medicaid on physician use by low-income children. Am J Pub Health 1986;79:1220–1126.

        • Rowland D.
        • Lyons B.
        Triple jeopardy.
        Health Serv Res. 1989; 23: 975-1004
        • Woolhandler S.
        • Himmelstein D.U.
        Reverse targeting of preventive care due to lack of health insurance.
        JAMA. 1988; 259: 2872-2874
        • Andersen R.M.
        • McCutcheon A.
        • Aday L.A.
        • et al.
        Exploring dimensions of access to medical care.
        Health Serv Res. 1983; 18: 50-74
        • Wenneker M.B.
        • Weissman J.S.
        • Epstein A.M.
        The association of payer with utilization of cardiac procedures in Massachusetts.
        JAMA. 1990; 264: 1255-1260
        • Soumerai S.B.
        • Avorn J.
        • Ross-Degan
        • Gortmaker S.
        Payment restrictions for prescription drugs under Medicaid.
        NEJM. 1987; 317: 550-556
        • Bradley C.M.
        • McMillan J.A.
        The impact of implementing a more restrictive prescription limit on Medicaid recipients.
        Med Care. 1996; 34: 686-701
      3. Chen M, Lyttle CS. Multivariate analysis of access to care. In: FM Anderson, LA Aday, CS Lyttle, et al, eds. Ambulatory Care and Insurance Coverage in an Era of Constraint. Cont. CHAS Res. Ser., No. 35. Cent. Health Adm. Stud., 1987.

        • Cornelius L.J.
        Access to medical care for black Americans with an episode of illness.
        J Natl Med Assoc. 1991; 83: 617-626
        • Sloan F.A.
        • Morrisey M.A.
        • Valvona J.
        Hospital care for the “self-pay” patient.
        J Health Polit Policy Law. 1988; 13: 83-103
        • Hadley J.
        • Steinberg E.P.
        • Feder J.
        Comparison of uninsured and privately insured hospital patients.
        JAMA. 1991; 265: 374-379
        • Franks P.
        • Clancy C.M.
        • Gold M.R.
        Health insurance and mortality.
        JAMA. 1993; 270: 737-741
        • Young G.J.
        • Cohen B.B.
        Inequities in hospital care, the Massachusetts experience.
        Inquiry. 1991; 28: 255-262
        • Braveman P.
        • Oliva G.
        • Grisham Miller M.
        • et al.
        Adverse outcomes and lack of health insurance among newborns in an eight county area of California, 1982-1986.
        NEJM. 1989; 321: 508-512
        • Ayanian J.Z.
        • Kohler B.A.
        • Abe T.
        • Epstein A.M.
        The relation between health insurance coverage and clinical outcomes among women with breast cancer.
        NEJM. 1993; 329: 326-331
        • Berg J.W.
        • Ross R.
        • Latourette H.B.
        Economic status and survival of cancer patients.
        Cancer. 1977; 39: 467-477
        • Lurie N.
        • Ward N.B.
        • Shapiro M.F.
        • Brook R.
        Termination from Medi-Cal. Does it affect health?.
        NEJM. 1984; 311: 480-484
        • Lurie N.
        • Ward N.B.
        • Shapiro M.F.
        • et al.
        Termination of Medi-Cal benefits. A follow-up study one year later.
        NEJM. 1986; 314: 1266-1268
        • Bindman A.B.
        • Keane D.
        • Lurie N.
        A public hospital closes.
        JAMA. 1990; 264: 2899-2904
        • Baker D.W.
        • Stevens C.D.
        • Brook R.H.
        Patients who leave a public hospital emergency department without being seen by a physician.
        JAMA. 1991; 266: 1085-1090
        • Stewart A.L.
        • Hays R.D.
        • Ware J.E.
        The MOS short form health survey.
        Med Care. 1988; 26: 724-732
        • Baker D.W.
        • Stevens C.D.
        • Brook R.H.
        Regular source of ambulatory care and medical utilization by patients presenting to a public hospital emergency department.
        JAMA. 1994; 271: 1909-1912
        • Pearson S.D.
        • Lee T.H.
        • Lindsey E.
        • et al.
        The impact of membership in an health maintenance organization on hospital admission rates for acute chest pain.
        HSR. 1994; 29: 59-74
        • Baker D.W.
        • Hayes R.D.
        • Brook R.H.
        Understanding changes in health status.
        Med Care. 1997; 35: 1-15
        • Duke K.S.
        Hospitals in a changing system.
        Health Affairs. 1996; 15: 49-61
        • Wennberg J.E.
        • Freeman J.L.
        • Culp W.J.
        Are hospital services rationed in New Haven or over utilized in Boston?.
        Lancet. 1987; 1: 1185-1189
      4. Billings J, Teicholz N. Uninsured patients in District of Columbia hospitals. Health Aff 1990;Winter:158–165.

        • Weissman J.S.
        • Gatsonis C.
        • Epstein A.M.
        Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland.
        JAMA. 1992; 268: 2388-2394
        • Goldman L.
        • Cook E.F.
        • Brand D.A.
        • et al.
        A computer protocol to predict myocardial infarction in emergency department patients with chest pain.
        NEJM. 1988; 318: 797-803
        • Brennan T.A.
        • Berwick D.M.
        New Rules. Jossey-Bass, San Francisco, Calif1995
        • Kellerman A.L.
        • Hackman B.B.
        Emergency department patient “dumping”.
        Am J Pub Health. 1988; 78: 1287-1292
        • Kellerman A.L.
        • Hackman B.B.
        Patient “dumping” post-COBRA.
        Am J Pub Health. 1990; : 80864-80867