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LETTER |
Bella M. Schanzer is with the Department of Psychiatry, Columbia University, New York, NY. Jeffrey A. Morgan is with the Department of Surgery, Columbia University, and is a surgical resident at Mount Sinai Medical Center, New York, NY.
Correspondence: Requests for reprints should be sent to Bella M. Schanzer, MD, Department of Psychiatry, Columbia University Medical Center, 600 W 168th St, 5th Floor, New York, NY 10032 (e-mail: bms12{at}columbia.edu).
In their editorial "Poverty, Race and the Invisible Men," Treadwell and Ro highlighted the dearth of health care services focused on underprivileged men.1 What the authors did not mention was that emergency departments (EDs) are being used, inappropriately, to fill the void.2–5 This population’s use of the ED as its usual source of care reflects a general trend that reflects both lack of regular primary care as well as health insurance or the funds to pay for appropriate outpatient care.2,6–8 Low-income and minority men are particularly affected by these problems and have begun to see the ED as their only option for care.
In a survey done in 2 EDs in Bronx, New York, we studied why men were overusing EDs. We surveyed all male ED users aged 18 years or older who presented to one of the EDs from 7:00 am to 1 am over a period of 2 months; the eventual sample size was 211 men. We sought to address how issues such as ethnicity, socioeconomic level, and insurance status affect ED and primary care utilization among men.
Not unexpectedly, the study results mirrored what had been found in the literature previously. Insurance status, employment status, and income were all found to be significantly related to ED use. Approximately 33% of uninsured patients and 60% of publicly insured patients used the ED at least twice in the 12 months before the study, while only 25% of privately insured patients did. Uninsured patients stated that they were most likely to use the ED as their primary source of care; only one third of uninsured and one seventh of publicly insured patients used private doctors’ offices, compared with nearly half of privately insured individuals.
Lower-income patients used the ED with a frequency 2.5 times that of higher-income patients. The majority of individuals who used the ED "in excess" (defined as 2 visits in 24 months) earned less than $20 000 per year. Among "abusers" of the ED (defined by 3 or more visits in 24 months), 90% earned less than $20 000 per year. "Abusers" were also twice as likely as nonabusers to be unemployed. Of note, we did not find a significant association between ethnicity and ED use.
Socioeconomic pressures are a major determinant of ED use among males. Not only are poor, uninsured, and unemployed men using the ED inappropriately for primary care, but, because they do not receive adequate primary care, they tend to present at a more acute stage of illness that often requires ED treatment.9 This bodes poorly for the men themselves as well as for the health care system, in which primary care is being shifted to overburdened and costly EDs. Clearly, this is a major problem facing the health care system. As noted by Treadwell and Ro, our society cannot continue to ignore the "invisible men."
References
1. Treadwell HM, Ro M. Poverty, race, and the invisible men. Am J Public Health.2003;93:705–707.
2. Walls C, Rhodes K, Kennedy JJ. The emergency department as usual source of medical care: estimates from the 1998 National Health Interview Survey. Acad Emerg Med.2002;9:1140–1145.[Web of Science][Medline]
3. Okuyemi KS, Frey B. Describing and predicting frequent users of the emergency department. J Assoc Acad Minor Phys.2001;12:119–123.[Medline]
4. Anson O, Carmel S, Levin M. Gender differences in the utilization of emergency department services. Women Health.1991;17:91–104.
5. Alvarez L, Fernandez A, Alvarez B. Role of primary care in the frequent attendance to the emergency service of a county hospital. Atención Primaria.1996;18:243–247.
6. Schull MJ, Szalai JP, Schwartz B, Redelmeier DA. Emergency department overcrowding following systematic hospital restructuring: trends at twenty hospitals over ten years. Acad Emerg Med.2001;8:1037–1043.[Web of Science][Medline]
7. Young G, Wagner M, Kellermann AL, Ellis J, Bouley D. Ambulatory visits to hospital emergency departments: patterns and reasons for use. JAMA.1996;276:460–466.
8. Grumbach K, Keane D, Bindman A. Primary care and public emergency department overcrowding. Am J Public Health.1993;83:372–378.
9. DeVoe JE, Fryer GE, Phillips R, Green L. Receipt of preventive care among adults: insurance status and usual source of care. Am J Public Health.2003;93:786–791.
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