Health policy and clinical practice/original research
Access to Emergency Care in the United States

https://doi.org/10.1016/j.annemergmed.2008.11.016Get rights and content

Study objective

Rapid access to emergency services is essential for emergency care–sensitive conditions such as acute myocardial infarction, stroke, sepsis, and major trauma. We seek to determine US population access to an emergency department (ED).

Methods

The National Emergency Department Inventories–USA was used to identify the location, annual visit volume, and teaching status of all EDs in the United States. EDs were categorized as any ED, by patient volume, and by teaching status. Driving distances, driving speeds, and out-of-hospital times were estimated with validated models and adjusted for population density. Access was determined by summing the population that could reach an ED within the specified intervals.

Results

Overall, 71% of the US population has access to an ED within 30 minutes, and 98% has access within 60 minutes. Access to teaching hospitals was more limited, with 16% having access within 30 minutes and 44% within 60 minutes. Rural states had lower access to all types of EDs.

Conclusion

Although the majority of the US population has access to an ED, there are regional disparities in ED access, especially by rurality. Future efforts should measure the relationship between access to emergency services and outcomes for emergency care–sensitive conditions. The development of a regionalized emergency care delivery system should be explored.

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

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    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.

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