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Assumptions vs Data

Manya F. Newton, MD, MPH, MS; Carla C. Keirns, MD, PhD, MA, MS; Rebecca Cunningham, MD; Rodney A. Hayward, MD; Rachel Stanley, MD, MHSA

JAMA. 2008;300(16):1914-1924.

Context  Emergency departments (EDs) are experiencing increased patient volumes and serve as a source of care of last resort for uninsured patients. Common assumptions about the effect of uninsured patients on the ED often drive policy solutions.

Objective  To compare common unsupported statements about uninsured patients presenting to the ED with the best available evidence on the topic.

Data Sources  OVID search of MEDLINE and MEDLINE in-process citations from 1950 through September 19, 2008, using the terms (Emergency Medical Services OR Emergency Service, Hospital OR emergency department.mp OR emergency medicine.mp OR Emergency Medicine) AND (uninsured.mp OR medically uninsured OR uncompensated care OR indigent.mp OR uncompensated care.mp OR medical indigency).

Study Selection  Of 526 articles identified, 127 (24%) met inclusion/exclusion criteria. Articles were included if they focused on the medical and surgical care of adult (aged 18 to <65 years) uninsured patients in emergency settings. Excluded articles involved pediatric or geriatric populations, psychiatric and dental illnesses, and non–patient care issues.

Data Extraction  Statements about uninsured patients presenting for emergency care that appeared without citation or that were not based on data provided in the articles were identified using a qualitative descriptive approach based in grounded theory. Each assumption was then addressed separately in searches for supporting data in national data sets, administrative data, and peer-reviewed literature.

Results  Among the 127 identified articles, 53 had at least 1 assumption about uninsured ED patients, with a mean of 3 assumptions per article. Common assumptions supported by the evidence include assumptions that increasing numbers of uninsured patients present to the ED and that uninsured patients lack access to primary care. Available data support the statement that care in the ED is more expensive than office-based care when appropriate, but this is true for all ED users, insured and uninsured. Available data do not support assumptions that uninsured patients are a primary cause of ED overcrowding, present with less acute conditions than insured patients, or seek ED care primarily for convenience.

Conclusion  Some common assumptions regarding uninsured patients and their use of the ED are not well supported by current data.

Author Affiliations: Robert Wood Johnson Clinical Scholars Program, University of Michigan School of Medicine, Ann Arbor (Drs Newton, Keirns, and Hayward); Department of Emergency Medicine (Drs Newton, Cunningham, and Stanley) and Division of General Medicine, Department of Internal Medicine (Drs Hayward, Newton, and Keirns), University of Michigan Medical Center, Ann Arbor; Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan (Drs Newton, Cunningham, and Stanley); Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor (Drs Newton, Hayward, and Cunningham); and Veterans Affairs HSR&D Center of Excellence, Ann Arbor VA Health System (Drs Hayward and Keirns).

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