Young adults have the highest rates of many preventable conditions,2,3,18
yet frequently lack a consistent source of ambulatory care.4,6
This study demonstrates that a considerable proportion of care delivered to young adults, especially black and uninsured young adults, occurs in the emergency department, greater than any other age group. Moreover, the use of the emergency department by young adults is increasing, suggesting that the current trends will likely progress without significant policy transformation.
Previous studies have suggested that adolescents overutilize emergency care,15
but this is the first study to examine emergency department utilization and trends by young adults. Visits from young adults were considerably more likely to occur in the emergency department rather than in an outpatient office setting compared to other ages, including adolescents. This finding likely represents a combination of relative overutilization of emergency services and underutilization of primary care. Young adults’ reliance on the emergency department is likely driven by many factors including lack of insurance, limited preventive care, inadequate transition of care between providers, and a lack of a usual source of primary care.4–6
We found that visits from uninsured patients were more likely than privately insured patients to occur in the emergency department, but this did not entirely account for young adults’ increased use of the emergency department. After accounting for young adults’ insurance status, injury status, and demographic factors, care continued to be considerably more likely to occur in the emergency department compared to other age groups, emphasizing the need to ensure access to a usual source of primary care.
Nearly half of all care provided to young black men in 2006 was delivered through emergency departments, considerably more than white young adults. Medical care was more likely to be delivered in the emergency department for both non-injury and injury-related complaints. Over the past decade, the number of ambulatory visits from black young adults has declined while the use of emergency services has increased. Black young adults’ greater use of the emergency department for health care may be related to several factors including barriers in accessing primary care, disparities in preventive care services, or inequalities in preventive counseling and health education.4,5,19
Improving access to appropriate ambulatory health care services with a consistent and culturally competent care provider could potentially help reduce disparities and improve overall health outcomes in young adults.
During a time when emergency departments are over-burdened,9,10
our results suggest that young adults, especially young black men, are becoming increasingly dependent on the emergency department for health care. While the use of the emergency department is certainly appropriate for many injuries and urgent medical complaints, we found that young adult visits were triaged as less urgent and required lower rates of admission to the hospital than other age groups, implying that ambulatory services would suffice for at least a portion of these visits. While young adults’ use of emergency care represents a small fraction of overall care provided by emergency departments, potential overuse has cost implications and places burdens on emergency departments while hindering continuity of care. Future initiatives, however, should focus on improving primary care for young adults, rather than limiting young adults’ access to emergency care.
Access to a usual source of primary care is associated with many improved health outcomes and lower rates of preventable hospitalizations and ED use.20,21
Improving access to primary care for young adults will require a multifaceted approach including improving transitions between providers, expanding health care coverage, and increasing awareness about the importance of a usual source of care. Historically, inadequate emphasis has been placed on ensuring adequate transition of care between pediatric and adult-focused providers,22–25
leaving many patients without a usual source of care as they become young adults.4
Additionally, transition of care often occurs at a time when many young adults lose health insurance coverage, further hindering access to care. Further advocacy is needed to support continuity of care across the transition into adulthood and to work towards expanding health care coverage. The Commonwealth Fund has proposed several potential options and policies to extend health coverage to young adults.6,26–28
Additionally, several states have adopted measures to extend coverage and several federal bills have been proposed,29–33
but tangible measures have yet to take hold nationally.
The use of NAMCS and NHAMCS data has several limitations. First, NAMCS and NHAMCS are visit-based, not person-based, and do not include visits to family planning centers, college or school based clinics, potentially leading to a small underestimation in the total amount of ambulatory care provided to young adults and an overestimation in the proportion of care received in the emergency department. In contrast, racial differences in college enrollment may lead to an underestimation of the disparity in utilization found in our analyses. Overall, the majority of health visits to college clinics occur at an age less than twenty-two, likely minimizing the effect on our analyses. Second, appropriateness of ED care is intrinsically very difficult to adequately measure. Our analyses concerning the acuity of emergency department visits were based on urgency at triage and hospital admission rates, similar to other studies.14,15
While these measures are imperfect and do not necessarily equate to appropriateness of ED visits, they do provide basic surrogate measures of acuity. Lastly, we do not have data on patients’ past medical history, health status, or whether a patient has an established primary care physician.