More patients who sought medical care at a declining number of California emergency rooms are a lot sicker, and slightly more of them required admission in 2007 than they did five years earlier, according to an analysis of facility discharge data from 10 of the state's largest counties.
The July report from the California HealthCare Foundation found that patients classified in the two most serious categories of illness rose from 25% to 34%. "California's EDs are facing a changing patient mix that may be putting pressure on their resources," the report's authors wrote. Not only are the patients requiring more emergency room evaluation and services, more of them need to be admitted.
Those in critical condition (defined as that which poses an immediate significant threat to life or physiologic function) rose from 9% of visits to 12%, while those in severe condition (requiring urgent evaluation, but not of immediate significant threat to life of physiologic function) rose from 16% to 22%.
"Severely ill ED patients, especially those who are admitted, require more resources and time to treat and may take up more ED bed capacity than a 'treat and discharge' patient," according to the report entitled "Is California's Hospital-Based ED System Eroding?"
Contrary to common belief that the bulk of people coming to hospital emergency rooms are uninsured, the report found that in 2007, private-pay patients with insurance used the emergency department the most. The study reported that 34% of all ED visits were by privately insured patients, while Medicaid (Medi-Cal) patients accounted for 24%, and Medicare 19%. Self-pay patients used the smallest proportion of ED visits, 16%.
Another finding is the steep increase in emergency room visits by people who did not have true emergencies, the report said. "Hospital EDs are becoming a source of primary care for a growing share of the population, leading to an increase in non-emergency ED visits from 578,000 in 2002 to 891,000 by 2007," the report said.
Also, more patients are leaving the ED without treatment "often after long waits."
Against this trend is the backdrop of a decline in the number of hospitals supporting emergency room services. Between 1996 and 2007, the number of hospitals declined from 481 to 436 while the number of emergency departments went from 388 to 344.
The majority of those EDs that closed were in urban areas. Overall, the report said, since 2001, the average travel distance to the nearest ED across the state changed little.
However, many of those hospitals that maintained emergency services increased their number of ED treatment bays. There were 4,994 ED beds statewide in 1996, but 6,310 ED beds in 2007, an increase greater than that of the population (15%) in that period. Hospitals that did not close expanded their emergency bed capacity to help meet the increased demand.
"Overall, there was an 8% rise in ED beds between 1996 and 2001and a 17% rise between 2001 and 2007," the report said, adding that this suggests EDs "are considered an essential service and that most hospitals have been able to manage external pressures in order to continue to offer ED services."
The report also found wide regional variation in emergency department capacity versus need throughout the state. For San Francisco, Fresno, Santa Clara, and Contra Costa counties, ED capacity outpaced demand for emergency care. In Sacramento, Los Angeles, and Kern counties, capacity kept up with demand. However, in San Bernardino, Riverside, and San Diego counties, demand exceeded increases in capacity.
Robbin Gaines, who is California HealthCare Foundation program officer, could not speculate on why there was so much variation between the counties, saying a more detailed analysis was necessary to determine if reimbursement or a mix of patients might be influential.
However, she noted, the lesson from the report is that "Emergency care is not 'one size fits all.' While statewide the number of ED beds has increased, there is substantial variation in ED systems across counties."