Tara
O'Neill Hayes November 1, 2018
Executive Summary
- Emergency department (ED) use has been increasing
steadily for decades, at a rate faster than U.S. population growth.
- One reason for rising ED use is aging demographics: The
elderly are more likely to have complex health conditions and need urgent
care. Other reasons include a lack of timely access to care in a doctor’s
office or other non-ED urgent care setting and technological improvements
that have changed and expanded the role EDs play in our health care
system.
- Policymakers and insurers are understandably concerned
about increased ED use, as it has relatively high treatment costs compared
with other care settings. While no other provider will every fully replace
EDs’ role in our health care system, improving access to primary care
could reduce ED utilization, as well as provide other benefits such as
greater preventive care and disease management.
- Overcrowding in the ED is also a concern. This
challenge stems not primarily from increased ED utilization but from
hospital-wide inefficiencies and overcrowding in the inpatient wards that
cause new patients awaiting admission to be “boarded” in the ED until
space becomes available. Improving access to primary care providers will
not resolve the overcrowding issue.
Introduction
Health care in the United States is expensive,
and part of the debate over how to control the cost of treatment has focused on
overuse of high-cost settings, such as hospital emergency departments (EDs).
Treating a patient in an ED costs much more than treating one in a primary care
setting, so overuse of EDs for non-urgent needs drives up overall spending, the
thinking goes. Insurers have taken note of this structure, and some have even
taken the step recently of refusing to cover beneficiaries’ unnecessary ED
visits.
Amid these changes, it is worth stepping back
and seeing what the data say about ED utilization. How many people are using
EDs? Who specifically is going, and why? And what is the relationship to
overall health care spending? Answers to these questions and others indicate
that while more people are going to EDs, the reason and the relationship to
overall health care spending is less clear.
Trends in Patient Volume
Patient volume in EDs has been growing faster
than the population for decades. In 1997, annual visits to the ED totaled 94.9
million (35.6 per 100 people).[1] By 2006, that total had increased 26
percent overall to 119.2 million, or 14 percent when adjusting for population
growth (40.5 per 100 people).[2] In 2015, ED visits had reached 136.9
million, or 43.3 per 100 people—a 7 percent increase from 2006 on a per capita
basis.[3]
The types of visits accounting for this growth,
however, are difficult to determine. The share of visits triaged as at least
“semiurgent”—that is, determined to need attention within two hours—grew
between 1997 and 2006, but appears to have been shrinking over the past decade,
as shown in the chart below.[4] A significant number of visits,
however, have an “unknown” triage level, particularly in 2015, which makes it
difficult to evaluate the real trend. The share of visits considered at least
semiurgent increased from 68 percent in 1997 to 75 percent in 2006, though the
share of ED visits that resulted in a hospital admission declined slightly from
13.5 percent in 1997 to 12.8 percent.[5],[6] In 2015, the share of visits (with a
known triage level) considered at least semiurgent had dropped to 64 percent
and only 9 percent of all ED visits resulted in a hospital admission.[7]
Other data show that the severity of cases seen
in the ED appears to be changing, particularly as non-ED acute care centers
become more readily available and accessible. Between 2008 and 2015, one study
found that the number of low-acuity visits to EDs decreased by 36 percent,
despite an overall increase in the number of low-acuity visits across all acute
care venues of 31 percent: Visits to non-ED care venues, such as urgent care
centers and retail clinics, increased 140 percent during this time period.[8] This jump indicates that people are
making better use of non-ED sites of care when they are able. On the other
hand, high-intensity visits have become more common in EDs. One study of
elderly Medicare beneficiaries showed high-intensity visits increased from 46
percent of all visits in 2006 to nearly 58 percent of visits in 2012.[9] This study found that this increase
was “moderately explained” by patient characteristics (particularly, the
presence of comorbidities) and an increase in services provided, indicating
that patients were presenting with a greater number of chronic conditions.
While this study does not account fully for the increase and leaves room for a
role of upcoding in boosting the numbers, in general this trend is likely to
continue as our elderly population continues to grow over the next few decades.
Other possible reasons for the increased rates
of ED utilization, discussed in more detail below, include: the increased
frequency with which primary care doctors refer patients to the ED, and the
continued difficulty patients face in accessing their primary care providers
through an unscheduled appointment or after regular office hours.
A very small share of patients use the ED quite
often. Patients with frequent ED use tend to use other health services at a
higher-than-average rate, have a typical source of primary care, and are more
likely to be covered by Medicare or Medicaid.[10] These individuals are also more
likely to have low incomes and poor physical and mental health.[11] Patients who visited the ED at
least four times in a single year accounted for only 8 percent of all ED users
but 28 percent of all ED volume.[12]
Patient Demographics
Age
Not surprisingly, the most common patients in an
ED by age on a per capita basis were infants less than a year old, visiting the
ED at a rate of 84.5 per 100 infants in 2006[13] and 102.2 per 100 in 2015.[14] For one, parents are much more
likely to take extreme caution with children of that age, particularly given
children’s inability to articulate clearly and accurately their pain and other
symptoms. Additionally, not all urgent care facilities have equipment suitable
for examining infants (particularly because of their size), so the ED may be
the only place available that can properly screen and treat them. The second
most common patients in an ED are people 75 years and older, at a rate of 60.2
per 100 people in that age group in 2006 and roughly unchanged in 2015.[15] People living in nursing homes, on
average, visited the ED more than once a year; in 2015, the rate per 100
nursing home residents was 150.6.[16] Obviously, health care needs tend
to increase as people age. Between 2006 and 2015, ED visits among 45 to 64
year-olds increased 20 percent, the greatest rate of increase among all age
groups, according to data from the Agency for Healthcare Research and Quality
(AHRQ).[17]
AHRQ also found that the percentage of visits to
the ED that result in hospital admission—one potential indication of an ED
visit’s appropriateness—has declined among all age groups recently, as shown in
the chart below.[18]
Insurance Coverage
The type of insurance held by people who are
going to EDs has been shifting. In 1997, well over three-fourths of individuals
visiting the ED had some form of insurance: 38 percent were privately insured,
18 percent were on Medicaid, and 16 percent were on Medicare, while 16 percent
had no insurance.[19] In 2006, the share of individuals
on Medicaid had increased significantly: 40 percent of people visiting the ED
were privately insured, 25 percent had Medicaid or CHIP, and 17 percent had
Medicare, while 17 percent had no insurance.[20] In 2015, the trend of an increasing
proportion of Medicaid patients using the ED continued: The share of privately
insured ED visitors had declined to 34.3 percent while the share of ED visitors
on Medicaid had significantly increased, reaching 34.8 percent and surpassing
the share of those privately insured. This increase was likely because of the
Affordable Care Act’s (ACA) expansion of Medicaid. In contrast, the share of ED
visits by Medicare beneficiaries remained roughly the same at 17.7 percent.[21] Presumably because of the ACA’s
insurance expansion, the share of uninsured individuals visiting the ED dropped
to just under 10 percent. Relative to individuals insured by other means,
Medicaid beneficiaries have been much more likely to use the ED and have become
increasingly more likely over time, as shown in the chart below. The privately
insured, on the other hand, are much less likely to use the ED, though from
1997 to 2006, the privately insured did become somewhat more likely to use the
ED and accounted for the majority of the growth in total ED visits. The share
of ED visits by uninsured individuals roughly matches the share of individuals
who are uninsured.
The difference in ED use between Medicaid
beneficiaries and the uninsured is likely primarily due to the poorer health of
Medicaid beneficiaries stemming from the greater prevalence of chronic disease.[22] Medicaid beneficiaries also have a
hard time accessing a primary care provider within a reasonable time and are
unworried about the financial cost of an ED visit because it will be covered
almost entirely by Medicaid, facts that likely also drive up ED visits for
Medicaid beneficiaries. In contrast, uninsured individuals can face the full
burden of the cost and thus likely use the ED only when they find it absolutely
necessary.
Race
In 2006, Black individuals visited the ED at
more than twice the rate of White or Hispanic people, a slight increase in the
rates seen 10 years earlier, though a smaller share of their visits were
considered to be urgent.[23] In 2015, the difference in ED visit
rates between Whites and Blacks narrowed slightly with Whites visiting the ED
at a slightly higher rate and Blacks visiting at slightly lower rates.[24]
There are several factors that might explain
this difference, particularly various social
determinants of health, including differences in insurance coverage:
Between 2015-2017, only 56 percent of Black individuals and 53 percent of
Hispanic individuals had private insurance coverage and 11 percent and 16
percent were uninsured, respectively, compared with the White population where
roughly 74 percent had private insurance and less than 7 percent were
uninsured.[25] This difference is largely a result
of differences in employment, which affects access to employer-sponsored
insurance (ESI). In 2016, 64 percent of White individuals had ESI, while only
46 percent of Black individuals and 41 percent of Hispanic individuals had ESI.[26] An individual’s health insurance
coverage is likely to affect their access to primary care, as explained below.
According to AHRQ, Black and Hispanic individuals have historically been less
likely to have a regular source of primary care compared to Whites.[27] Another study found that the total
time burden for receiving ambulatory medical care was up to 28 percent greater
for racial and ethnic minorities and unemployed individuals.[28]
Reasons for Using the ED Rather than Other Care
Settings
ED use is a reflection of the health needs in a
community and the accessibility of other sources of care there. An individual’s
decision to seek care in the ED is primarily a factor of how quickly the person
believes they need to be treated. This decision depends on the severity of the
patient’s symptoms along with their ability to obtain a timely appointment in a
setting other than the ED that is convenient for them. Studies continuously
find that the ED is almost never patients’ first choice of location to receive
non-urgent care, but they go there because of a lack of other options
(perceived or otherwise).
Patient Symptoms
Injuries are typically the most common reason
for a visit to the ED, accounting for 37 percent of ED visits in 1997[29] and 36 percent of visits in 2006.[30] In 2015, the share of
injury-related visits dropped to 30 percent, roughly 1 million fewer than in
2006.[31] The share of unintentional
injury-related visits to EDs, however, rose roughly 9 percentage points,
and the share of visits related to adverse effects of medical treatment and
medical and surgical complications increased 1 percentage point.[32] In each year, the most common cause
for injuries treated in the ED was falls, followed by motor vehicle accidents.
Beyond injuries, symptoms related to the respiratory, digestive, and
musculoskeletal systems were the next most common causes for ED visits.[33] Specifically, the three most common
complaints in 1997 were stomach/abdominal pain, chest pain, and fever, and
continued to be so in 2006 and 2015.[34] These types of symptoms, while
often not serious, could be indicative of a true emergency, such as a heart
attack, ruptured appendix or other organ, or serious illness. Patients also
often believe their condition is more urgent than it truly is and err on the
side of caution, likely a reason for so many visits that are ultimately
determined to be non-urgent. It is not just patients, however, who sometimes
inappropriately judge their condition; one study found that 5.5 percent of
patients initially determined by hospital clinicians to present non-urgent
conditions were later admitted as inpatients.[35] Another study found potentially
preventable ED visits increased at a faster rate than ED visits overall from
2008 to 2012, and mental health-related visits increased the most relative to
all other nonmaternal treat-and-release ED visits.[36]
In 1997, 29 percent of all hospital admissions
resulted from an ED visit; in 2006, that percentage had increased to 41
percent.[37] In 2010, that figure continued to
rise, and ED visits accounted for nearly half of all hospital admissions (47
percent), but that trend then began to reverse, and in 2015 ED visits accounted
for 35 percent of all hospital admissions.[38] This recent trend reversal may be
because ED physicians have increased the intensity of services provided to
patients in EDs which may be allowing more people to be discharged rather than
needing to be admitted, as discussed below.
Of people admitted to the hospital following
their arrival in the ED in 2006, roughly an equal share of patients were
covered by private insurance as were covered by Medicare (43 percent and 42
percent, respectively), and 20 percent were covered by Medicaid or the Children’s
Health Insurance Program (CHIP). In 2015, 48 percent were Medicare
beneficiaries, 38 percent were privately insured, and 28 percent were
Medicaid/CHIP beneficiaries.[39] These changes are likely more
indicative of overall changes in sources of insurance coverage following
passage of the ACA and its expansion of Medicaid eligibility, rather than
changes in the health or behaviors of people covered by each type of insurance.
Improved Technology
The role of EDs has been changing as new
technology is developed. Because EDs have to be prepared for any and all
emergencies, they typically have the most up-to-date medical technology.
Improved diagnostic capabilities allow providers to diagnose patients much more
quickly, and these technologies—whether imaging devices or laboratory tests—are
most likely to be immediately available at an ED. Because of these advantages,
providers are more likely to refer patients to the ED and patients are more
likely themselves to go to an ED if a quick diagnosis is needed.[40]
The data show there has been an increase in
treatment intensity in the ED, and this may be reducing the number of people
who are ultimately admitted to the hospital. According to one study,
high-intensity visits grew from 46 percent in 2006 to 58 percent in 2012; the number
of services provided increased for both admitted and discharged patients.
Simultaneously, there was a reduction in the hospital admission rate from 40
percent to 36 percent.[41] Another study found similar results:
The rate of ED visits that resulted in a discharge increased while the rate of
potentially preventable inpatient stays for the same conditions decreased.[42] The increased intensity can have
differing effects. While costs related to care in the ED may be increasing as a
result, overall spending may decline if expensive inpatient stays are avoided.
Other studies conclude that despite no net change found in the proportion of
lower-acuity visits and a reduction in the amount of time lower-acuity patients
spend in the ED, the growing intensity of interventions for higher-acuity
patients—including blood tests, advanced imaging, intravenous fluids, and
medication administration—may be the primary reason for increasing occupancy in
the ED.[43] Further, the authors of that study
concede that it is difficult to know the cost-effectiveness of this new norm.
Lack of Access to Primary Care
Many barriers to accessing timely outpatient
care have been associated with increased ED utilization.[44] To the extent that an individual
believes their symptoms or injury requires immediate attention, the fact that
settings other than EDs will typically not see them quickly without an
appointment often makes them untenable options.
Several studies have shown utilization does
increase when physician offices are typically closed. One study found that 75
percent of ED visits among children in 2012 were at night or on a weekend, and
that, regardless of insurance status, this lack of access elsewhere was the
most common reason given for visiting an ED for non-urgent conditions (i.e.
conditions that can wait to be treated for up to 24 hours).[45]
A study from 2013 found no significant increase
in utilization after normal working hours or on weekends; use occurred even
when other health clinics were open.[46] The mere fact that other options
were open, however, does not necessarily mean that they were therefore
available; a doctor’s office may be open but not accepting walk-in
appointments. One study found that 22 percent of non-urgent ED patients had
tried but failed to access primary care first.[47] Nearly half of patients who
described the ED as their usual source of care had tried to obtain an
appointment with a primary care physician.[48] Their failure was likely due, at
least partially, to the fact that over one-fourth of primary physicians were
found not to be accepting new Medicaid patients, and more than one-fifth would
not accept new patients who lacked insurance.[49] This lack of access likely also
explains the greater ED use among Medicaid patients relative to those privately
insured. Only 5 percent of primary care physicians surveyed were not accepting
new patients with private insurance. A Medicaid and CHIP Payment and Access
Commission (MACPAC) report from July 2014 found that access to primary care was
a primary factor in whether a Medicaid beneficiary would use the ED and found
little evidence of inappropriate use of the ED.[50]
The Congressional Research Service found that ED
use is lower in areas with federal health centers,[51] and ED use has been found to be
greater in areas that have limited ambulatory care capacity and a greater
supply of ED capacity.[52] The Health Resources and Services
Administration currently designates more than 6,700 areas across the United
States as having a shortage of primary care providers and more than 4,200 areas
as being medically underserved.[53] Though, the increase in the number
of alternative care options—such as retail clinics now commonly found at CVS,
Wal-Mart, Target, and other retailers, as well as expanded telehealth
services—may be mitigating this problem somewhat, as discussed earlier.
Others utilize the ED rather than a physician’s
office or health clinic because of a perception that care provided in the
hospital is going to be of greater quality or because it is seen as the only or
easiest option for accessing a specialist.[54]
Effect of Increased Utilization: Overcrowding
Despite the ACA’s coverage expansion, overcrowding of
EDs continues to be an issue. Numerous studies find overcrowding in the ED to
be a symptom of overcrowding elsewhere in the hospital, rather than a result of
an influx of patients in the ED. This overcrowding is typically caused by
hospital inefficiencies and a scarcity of inpatient beds or key clinical staff
which forces patients to be kept inappropriately in the ED while they wait to be
admitted (a practice known as “boarding”).[55]
The primary downside to increased ED utilization
and overcrowding is the difficulty it creates in tending to patients with a
true emergency in a timely fashion. Hospitals have limited resources, and the
more patients seeking care in the ED, the longer it will take to be seen. A
study published in 2010 found that despite only 4 percent of physicians in the
United States working in the ED, these physicians were responsible for 28
percent of all acute care visits.[56]Nonetheless, ED physicians work hard to
ensure that patients with nonurgent conditions are treated and released
quickly. A study in 2007 found that patients with needs determined to be of
“low-complexity” had a negligible increase in the length of stay for patients
in the ED and in the amount of time before other patients’ first contact with a
physician.[57] Some hospitals have implemented
protocols to enable such patients to be treated and discharged quickly,
sometimes by dedicating a certain area and a team of providers specifically to
deal with these low-complexity cases.
Overcrowding can lead hospitals to impose
ambulance diversion policies which can have negative effects on patients,
including both those who are diverted to a hospital further away and those who
then have to wait longer for an ambulance to reach them since it has just
traveled farther away.[58] Such diversion practices may be
causing increased disparities in health outcomes between White and Black
individuals.[59]
Further, adverse events are more likely to occur
when hospitals are at capacity, which is highly correlated with ED overcrowding
and “boarding.”[60] Boarding was found to increase
patients’ morbidity, the length of their hospital stay, and their mortality.[61] Overcrowding also limits the
capacity to respond to a major disaster. If hospital inefficiencies persist and
“boarding” remains prevalent, continued increased use of the ED will certainly
make overcrowding worse.
Costs and Expenditures
Because health care costs vary so widely across
regions and within regions, studies attempting to compare costs between EDs and
other sites of care produce varying results regarding the magnitude of
the difference, but they all consistently find that care provided in an
emergency room is more expensive than care provided elsewhere. According to
AHRQ, the average cost of a primary care visit was $199 in 2008 while the
average cost of a doctor visit in the ED was $922.[62] Another study found the median
charge for 10 different outpatient conditions treated in the ED between
2006-2008 was $1,233.[63] According to one insurer’s charges
in 2012, costs in urgent care ranged from 17 to 28 percent of the cost for
treating the same condition in the ED.[64] In Texas, costs in the ED were
found to be 10 times greater than costs at urgent care centers from 2012-2015.[65]
Part of the higher cost is due to the greater
regulatory burden, which costs hospitals $39 billion annually, according to an
American Hospital Association estimate.[66] Another reason hospitals charge so
much for care in their EDs is so they can cross-subsidize uncompensated care
(estimated to reach a peak of more than $46 billion in 2013 and then to fall to
$39 billion in 2016).[67] This cross-subsidization is
typically financed by private payers: Private insurers have consistently paid
roughly half of all ED expenditures (as shown in the chart below), despite
typically only covering 35 to 40 percent of ED patient visits.[68] The high rate of uncompensated care
is somewhat caused by the provisions of the Emergency Medical Treatment and
Active Labor Act, which requires any patient be stabilized before being
discharged from a hospital, regardless of the patient’s ability to pay.[69] A third reason for the higher costs
in the ED is the greater overhead costs associated with the amount of
technology that is kept on-hand in an ED so that the staff is prepared to
respond to any type of emergency that may arise. As emergencies can occur at
any time of day or night, EDs must be open 24 hours and specialists of all
kinds must be on-call 24 hours a day, every day, which is certainly costly, as
they must be paid for their time on-call whether they treat anyone or not.
Finally, some of the greater cost may also result from the fact that most
people treated in an ED are seen by both an attending physician and a
registered nurse (RN). In 1997, 87 percent of people in the ED were seen by an
RN, and 86 percent were seen by a staff physician.[70] By 2015, those percentages had
increased slightly: 94 percent were seen by an RN or licensed nurse
practitioner and 88 percent of people saw a physician, including 85 percent who
saw an attending physician.[71]
Even though hospitals charge so much and total
ED visits have been growing, total ED expenditures have accounted for on
average just 2 percent of total national health expenditures for years, ranging
from 1.6 percent in 1997 to 2.2 percent in 2014.[72] Expenditures for ED services have
increased dramatically in dollar figures, however, from $16.9 billion in 1997
to $65.4 billion in 2014, just as total health expenditures have increased. As
noted earlier, some of this increase in ED expenditures may be the result of
the noted increase in the intensity of services provided in the ED. But what is
not yet known and worth considering is the large potential savings that may be
occurring as a result in the form of costs avoided by preventing hospital
admissions.
The following chart shows the share of ED
expenses paid out-of-pocket (OOP) by individual’s poverty status.[73] While all income groups have
recently experienced a reduction in the share of expenses paid OOP, there is a
rather significant decline in the share of expenses paid by people near or
below the poverty line following passage of the ACA.
Conclusion
Use of EDs has been increasing steadily for
decades, at a rate faster than our population growth, as their role in our
health care system has expanded. The increased utilization is the result of
many factors, including: the changing demographics of our population
(particularly the growing number of elderly people who typically have greater
health care needs), a lack of timely access to care in other settings, more
frequent referrals to the ED by primary care physicians, and the availability
of improved technology that makes the ED a preferred option for patients
looking for a quick diagnosis. Individuals covered by Medicaid are most likely
to use the ED.
Because care provided in the ED is typically
much more expensive than if it were provided in a primary care facility—such as
a doctor’s office, an urgent care center, or retail clinic—insurers and
policymakers concerned with growing health care costs are looking for ways to
reverse this trend. Increased ED use and overcrowding also strain hospitals’
limited resources and make it more difficult to ensure patients with true
emergencies can be treated in a timely manner—though the real culprit of ED
overcrowding is hospital-wide inefficiencies that result in patients “boarding”
in the ED while they wait to be admitted to an inpatient ward, rather than
excessive use for non-urgent care. When EDs become overcrowded, patients
experience worse health outcomes.
ED utilization could be decreased by improving
access to primary care, allowing for greater preventive care and disease
management, and greater availability of same-day appointments to respond to
injuries or a sudden onset of alarming symptoms or illness. Real improvements
will likely not be seen, though, unless there are significant improvements in
hospital efficiency and management such that patients are no longer “boarded”
in the ED, taking up valuable bed space.
[2] Pitts,
Stephen & Niska, Richard & Xu, Jianmin & W Burt, Catharine. (2008).
National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department
Summary. National health statistics reports. 2.
[4] A
visit categorized as “emergent” indicates the patient should be seen within
1-14 minutes; urgent: 15 mins-1 hour; semiurgent: 1-2 hours; and nonurgent:
within 24 hours.
[5] Pitts,
Stephen & Niska, Richard & Xu, Jianmin & W Burt, Catharine. (2008).
National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department
Summary. National health statistics reports. 17.
[8] Poon
SJ, Schuur JD, Mehrotra A. Trends in Visits to Acute Care Venues for Treatment
of Low-Acuity Conditions in the United States From 2008 to 2015. JAMA
Intern Med. 2018;178(10):1342–1349. doi:10.1001/jamainternmed.2018.3205
[9] Burke
LG, Wild RC, Orav EJ, et al Are trends in billing for high-intensity emergency
care explained by changes in services provided in the emergency department? An
observational study among US Medicare beneficiaries BMJ Open 2018;8:e019357.
doi: 10.1136/bmjopen-2017-019357
[13] Pitts,
Stephen & Niska, Richard & Xu, Jianmin & W Burt, Catharine. (2008).
National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department
Summary. National health statistics reports. 2.
[15] Pitts,
Stephen & Niska, Richard & Xu, Jianmin & W Burt, Catharine. (2008).
National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department
Summary. National health statistics reports. 2.
[16] Pitts,
Stephen & Niska, Richard & Xu, Jianmin & W Burt, Catharine. (2008).
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Summary. National health statistics reports. 2, https://www.cdc.gov/nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf (Table
2)
[17] https://www.hcup-us.ahrq.gov/reports/statbriefs/sb238-Emergency-Department-Age-Payer-2006-2015.jsp?
[18] https://www.hcup-us.ahrq.gov/reports/statbriefs/sb238-Emergency-Department-Age-Payer-2006-2015.jsp?
[20] Pitts,
Stephen & Niska, Richard & Xu, Jianmin & W Burt, Catharine. (2008).
National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department
Summary. National health statistics reports. 15.
[23] https://www.ncbi.nlm.nih.gov/pubmed/18958996, https://www.semanticscholar.org/paper/National-Hospital-Ambulatory-Medical-Care-Survey%3A-McCaig-Stussman/2515606778df546c97a8f44fd075ce4cf040c150/figure/1, https://www.semanticscholar.org/paper/National-Hospital-Ambulatory-Medical-Care-Survey%3A-McCaig-Stussman/2515606778df546c97a8f44fd075ce4cf040c150/figure/13
[26] https://www.kff.org/other/state-indicator/rate-by-raceethnicity-2/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
[29] https://www.semanticscholar.org/paper/National-Hospital-Ambulatory-Medical-Care-Survey%3A-McCaig-Stussman/2515606778df546c97a8f44fd075ce4cf040c150/figure/15
[30] Pitts,
Stephen & Niska, Richard & Xu, Jianmin & W Burt, Catharine. (2008).
National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department
Summary. National health statistics reports. 24.
[33] https://www.semanticscholar.org/paper/National-Hospital-Ambulatory-Medical-Care-Survey%3A-McCaig-Stussman/2515606778df546c97a8f44fd075ce4cf040c150/figure/15
[34] https://www.semanticscholar.org/paper/National-Hospital-Ambulatory-Medical-Care-Survey%3A-McCaig-Stussman/2515606778df546c97a8f44fd075ce4cf040c150/figure/17,
Pitts, Stephen & Niska, Richard & Xu, Jianmin & W Burt, Catharine.
(2008). National Hospital Ambulatory Medical Care Survey: 2006 Emergency
Department Summary. National health statistics reports. 22.
[36] https://www.hcup-us.ahrq.gov/reports/statbriefs/sb195-Potentially-Preventable-Hospitalizations.pdf
[41] Burke
LG, Wild RC, Orav EJ, et al Are trends in billing for high-intensity emergency
care explained by changes in services provided in the emergency department? An
observational study among US Medicare beneficiaries BMJ Open 2018;8:e019357.
doi: 10.1136/bmjopen-2017-019357
[42] https://www.hcup-us.ahrq.gov/reports/statbriefs/sb195-Potentially-Preventable-Hospitalizations.pdf
[43] Kocher,
Keith E. et al, “Emergency Department Crowding 2.0: Coping With a Dysfunctional
System.” Annals of Emergency Medicine, Volume 60 , Issue 6 , 687 – 691
[45] Renee
M. Gindi and Lindsey I. Jones, Reasons for Emergency Room Use Among U.S.
Children: National Health Interview Survey, 2012, U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, National Center for
Health Statistics, NCHS Data Brief: No. 160, Hyattsville, MD, July 2014.
[56] Stephen
R. Pitts et al., “Where Americans Get Acute Care: Increasingly, It’s Not at
Their Doctor’s Office.” Health Affairs, vol. 29, no. 9 (September 2010), pp.
1620-1629.
[65] “Comparing
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Emergency Medicine , Volume 70 , Issue 6 , 846 – 857.e3
[68] Agency
for Healthcare Research and Quality. Emergency Room Services-Mean and Median
Expenses per Person With Expense and Distribution of Expenses by Source of
Payment: United States. Medical Expenditure Panel Survey Household Component
Data. Generated interactively.
[70] https://www.semanticscholar.org/paper/National-Hospital-Ambulatory-Medical-Care-Survey%3A-McCaig-Stussman/2515606778df546c97a8f44fd075ce4cf040c150/figure/9
[72] Agency
for Healthcare Research and Quality. Emergency Room Services-Mean and Median
Expenses per Person With Expense and Distribution of Expenses by Source of
Payment: United States, 2014. Medical Expenditure Panel Survey Household
Component Data. Generated interactively. (July 23, 2018), and https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html
[73] Agency
for Healthcare Research and Quality. Emergency Room Services-Mean and Median
Expenses per Person With Expense and Distribution of Expenses by Source of
Payment: United States. Medical Expenditure Panel Survey Household Component
Data. Generated interactively.
https://www.americanactionforum.org/research/primer-examining-trends-in-emergency-department-utilization-and-costs/#ixzz5VjdLFMRU
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