Health policy and clinical practice/original researchAccess to Emergency Care in the United States
Introduction
Time-sensitive interventions, such as coronary revascularization in acute myocardial infarction,1, 2 fibrinolytic therapy for acute ischemic stroke,3 early goal-directed therapy in sepsis,4 and trauma center care for severe injury,5 highlight the importance of timely, universal access to care for emergency care–sensitive conditions. Receipt of these interventions is contingent on access to an appropriately equipped and staffed emergency department (ED) or an ED that can triage, stabilize, and rapidly transport patients to more definitive care.
Understanding which EDs have adequate resources to care for patients with emergency care–sensitive conditions is difficult. A common perception is that higher-volume teaching EDs located at referral hospitals provide more comprehensive care than their smaller community counterparts.6 No centralized data collection system exists that characterizes ED capabilities or the resources available within their parent hospitals. This lack of knowledge about individual EDs is an important barrier for researchers and health services planners alike. Researchers cannot determine the relationship between access and resources for emergency care–sensitive conditions, and planners cannot develop systems to efficiently deliver patients to the most appropriate level of care.
Although details in terms of ED capabilities and resources are as yet unavailable for the nation, the basic distribution and characteristics of EDs in the United States has been recently compiled.7 To date there have been no population-based estimates of access to these EDs. We therefore sought to generate national estimates of access to various types of EDs within 30, 45, and 60 minutes. These findings have important policy implications for future ED categorization, credentialing, and the regionalization of emergency care.8
Section snippets
Theoretical Model of the Problem
The traditional framework describing access to care includes 5 important domains: availability, accessibility, accommodation, affordability, and acceptability.9 For the subset of conditions requiring prompt intervention to optimize outcome, accessibility to emergency care represents the most important domain. A basic understanding of the location of emergency care facilities relative to the population requiring prompt access to these resources is an essential first step in developing an
Results
The 2003 National Emergency Department Inventories–USA database identified 4,809 hospitals with general receiving EDs; the sum of all ED visits was 113.3 million visits, which is consistent with the 113.9 million ED visit estimate from the sample of hospitals that participate each year in the US National Hospital Ambulatory Medical Care Survey.18 The median number of annual visits was 18,089. About one third (n=1,358) of EDs treated fewer than 8,760 patients per year. Of the 3,451 EDs that
Main Results
Overall, 71% of the US population has access to an ED within 30 minutes, 94% within 45 minutes, and 98% within 60 minutes. The Northeast had the greatest access within 30 minutes (76%), followed by the West (71%), the Midwest (70%), and the South (68%). Access was much less variable within 60 minutes, ranging from 99.5% in the Northeast to 97% in the West (Table 1;Figure 1).
Overall, access to EDs with higher volume (≥1 visit/hour) was similar, with 68% of the population having access within 30
Limitations
We provide a population-level analysis of access to EDs. As such, the estimated travel times may not be directly applicable on the individual level. We believe our inventory of EDs to be comprehensive; however, it remains possible that EDs have been omitted. We think it is more likely, however, that we have included clinics that self-describe as an “ED” but that are not open round the clock or to all comers, key characteristics of an ED. This possibility would lead us to overestimate ED access.
Discussion
We provide national, regional, and statewide access estimates to EDs by volume and by teaching status. We demonstrate that the majority of the US population has access to an ED within 60 minutes and demonstrate variability by region and state for higher-volume EDs and teaching EDs. Living in a rural area is a key driver of these results because we observed a strong linear relationship between the population of a state living rurally and overall resident access to emergency care.
The central
References (38)
- et al.
Importance of time to reperfusion on outcomes with primary coronary angioplasty for acute myocardial infarction (results from the Stent Primary Angioplasty in Myocardial Infarction Trial)
Am J Cardiol
(2001) - et al.
A profile of US emergency departments in 2001
Ann Emerg Med
(2006) The Zerhouni challenge: defining the fundamental hypothesis of emergency care research
Ann Emerg Med
(2007)- et al.
ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summaryA report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)
J Am Coll Cardiol
(2004) - et al.
Emergency medicine resident choice of practice location
Ann Emerg Med
(1998) - et al.
Emergency medical care in rural America
Ann Emerg Med
(2001) - et al.
Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction
JAMA
(2000) Tissue plasminogen activator for acute ischemic stroke
N Engl J Med
(1995)- et al.
Early goal-directed therapy in the treatment of severe sepsis and septic shock
N Engl J Med
(2001) - et al.
A national evaluation of the effect of trauma-center care on mortality
N Engl J Med
(2006)
Academic health centers: exploring a financial paradox
Health Aff (Millwood)
Hospital Based Emergency Care: At the Breaking Point
The concept of access: definition and relationship to consumer satisfaction
Med Care
National Emergency Department Inventory-USA
Member Teaching Hospitals and Health Systems
Census 2000 Datasets
Centers of population computation for 1950, 1960, 1970, 1980, 1990 and 2000. US Census Bureau, April 2001
A meta-analysis of prehospital care times for trauma
Prehosp Emerg Care
Access to trauma centers in the United States
JAMA
Cited by (130)
National Trends in the Use of Specialty Consultations in Emergency Department Visits, 2009 to 2019
2023, Annals of Emergency MedicineExploring Which Patients Use Their Closest Emergency Departments Using Geocoded Data
2023, Journal of Emergency MedicineTrends in Pulmonary Embolism Deaths Among Young Adults Aged 25 to 44 Years in the United States, 1999 to 2019
2023, American Journal of CardiologyLocating emergency medical services to reduce urban-rural inequalities
2022, Socio-Economic Planning SciencesEmergency Care Sensitive Conditions in Brazil: A Geographic Information System Approach to Timely Hospital Access
2021, The Lancet Regional Health - AmericasA Community-Engaged Approach to Understanding Suicide in a Small Rural County in Georgia: A Two-Phase Content Analysis of Individual and Focus Group Interviews
2023, International Journal of Environmental Research and Public Health
Provide feedback on this article at the journal's Web site, www.annemergmed.com.
Supervising editor: Donald M. Yealy, MD
Author contributions: BGC, CCB, JPM, and CAC conceived of and designed the study. BGC, AFS, and CAC obtained the data. BGC drafted the article. All the authors interpreted the data, revised the article, and contributed substantively to the work. BGC takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. The study was supported by the Robert Wood Johnson Foundation and the National Library of Medicine (R21LM008700).
Publication date: Available online February 3, 2009.
Reprints not available from the authors.