Low-income and poorly insured patients are at a disproportionately increased risk of leaving emergency departments without being seen, according to an analysis of 262 California hospitals.
The proportion of patients who leave emergency departments (EDs) without being seen has increased significantly over the last 15 years, as strains on the emergency care system have mounted. And, although it’s logical to assume that vulnerable populations and the hospitals that serve them are at greatest risk, there are few multicenter studies to show it, said Dr. Renee Y. Hsia of the University of California, San Francisco, and her associates (Ann. Emerg. Med. 2011 Feb. 21 [doi:10.1016/j.annemergmed.2011.01.009]).
"Patients who leave without being seen from an ED are a glaring measure of impaired health care access. Their observed behavior represents individual attempts to enter the health care system without success. Our study provides descriptive data about [patients who] left without being seen from a large statewide cohort of hospital EDs. ... The increasing phenomenon of left without being seen patients differentially affects those at hospitals that tend to serve the most vulnerable. Real action and resources should be applied to address the disparities on a systems level," the investigators said.
The retrospective cohort study included all ED visits to acute, nonfederal hospitals in California in 2007. Study data for 288 hospitals were obtained from the California Office of Statewide Health Planning and Development, which mandates standardized reporting on all ED visits to nonfederal hospitals in the state. Excluded were 26 hospitals that reported a 0% incidence of left without being seen, which was deemed inaccurate based on a manual review.
The remaining 262 hospitals represented 9.2 million ED visits. The mean number of visits in which an individual left the ED without being seen was 35,034 per year, with a median of 31,079 and a range of 5,721-133,968. The median overall rate was 2.6%, with a range of 0.06%-20%.
Higher patient income and higher hospital operating margins were associated with a lower probability of leaving without being seen, whereas greater proportions of minority and more Medi-Cal/uninsured patients were associated with a higher probability. Teaching hospitals, county-owned hospitals, and trauma centers were associated with higher probabilities of left without being seen, compared with nonteaching, non–county-owned, and nontrauma centers, Dr. Hsia and her associates said.
Specifically, each 10 percentage point increase in a hospital’s proportion of poorly insured patients was associated with an odds ratio of left without being seen of 1.15, whereas each $10,000 increase in patients’ average income was associated with an odds ratio of 0.86.
County-owned facilities, teaching hospitals, and trauma centers experienced much higher rates of left without being seen, compared with not-for-profit facilities, with odds ratios of 1.62, 2.14, and 2.09, respectively. Supplementary analysis showed that facilities serving more of the uninsured or Medi-Cal populations are more likely to be these types of institutions, the authors noted.
For hospitals serving areas at the lowest 10th percentile of income (median, $33,150), the left without being seen rate was 3.4%, compared with 1.7% in hospitals serving populations at the 90th income percentile (median, $65,110). Similarly, the predicted left without being seen rate for visitors to county-owned hospitals was 5.0% vs. 2.5% for not-for-profit hospitals, 5.1% for teaching hospitals vs. 2.5% for nonteaching hospitals, and 3.9% for trauma centers vs. 2.5% for nontrauma centers.
California represents 12% of the U.S. population and 7% of the U.S. hospital market, yet it actually has a lower number of ED visits per 1,000 population compared with national estimates (274 vs. 401 in 2007). Thus, the numbers of left without being seen are likely to be conservative, Dr. Hsia and her associates said.
"These findings provide further evidence that, when access is measured not as a process but as an outcome ... the current health care market does not serve vulnerable populations equitably," they concluded.
Individual study authors were supported by the Emergency Medicine Foundation, the Agency for Healthcare Research and Quality, the UCLA Older Americans Independence Center, a grant from the National Center for Research Resources of the National Institutes of Health, and/or the Robert Wood Johnson Foundation. No other disclosures were made.