While research has
examined ED use by rural elderly Americans in 3 rural communities
,26 111 counties in one state
,25 and 2 states
to our knowledge this is the first study that
has investigated factors associated with ED use exclusively among the community-dwelling (non-institutionalized) rural elderly for the entire United States. We found that being a widow or widower, having more than a high school education, being enrolled in Medicaid (but not Medicaid managed care), having fair or poor self perceived physical health, and reporting respiratory diseases or
heart diseases increased the likelihood of having any ED visits. Enrollment in Medicaid managed care and residence in the western U.S. were associated with lower probability of having any visits.
We found that about 20% of the community-residing rural elderly had at least one ED visit, which is approximately what Lisher and colleagues found for Medicare beneficiaries in Washington state in 1994.27
The most frequent diagnoses for ED visits in the present study were similar to those found in previous studies: circulatory system diseases, injury, and respiratory system diseases.24,27
We used the Andersen behavioral model for our conceptual framework. Although the model has been widely used, concerns about its utility have been raised.29,53
One concern is that the model may work better for some types of health services. However, few studies have attempted to modify it, particularly for ED use.3
Another concern is that the model may have different utility for different populations. Previous studies have found it to be a poor predictor of physician, hospital, and dentist utilization among the elderly with only need characteristics as significant predictors.53
However, we found that not only need factors but also predisposing (marital status and education) and enabling (Medicaid enrollment, Medicaid managed care) factors as well as an interaction between a need and an enabling variable are significant predictors of ED use among the rural elderly.
Marital status as a significant determinant of any ED use is seldom documented in previous work.41,53
Only one study53
reports a positive association between being widowed and ED use. There are several possible explanations for our finding
. It may be because widowed persons have worse health status.54
Even though we have controlled for health status our
variables may not be sufficient. Second
, married people might have access to better information and a superior referral network.55
A third reason is the impact of marital status change on healthcare use.54
However, we do not have the detailed
to determine whether this is the case
The literature that has investigated the factors associated with having any ED visits has mixed evidence about the impact of age.3
In most studies, older age has been associated with increased ED use in bivariate analysis. However, in multivariate analysis it is statistically significant in only a few studies.3,27,30,56
Our study found a similar pattern. Age is an enabling factor primarily through its relationship to other factors such as health. Controlling for other factors could mitigate the age effect.
Both Medicaid enrollment and fair/poor
self-rated physical health were found to be independently associated with increased probability of having any ED use, which is
consistent with previous research.27,36,39,41,42
Further, we found an interaction between these two factors. For persons reporting excellent, very good, good, and fair self-rated physical health status, individuals on Medicaid are more likely to have at least one ED visit than those not on Medicaid. Further, while the evidence is not completely consistent, among
persons reporting poor physical health Medicaid enrollees may be
less likely to have any ED visits.
It should be noted that elderly Medicaid enrollees are dual eligible beneficiaries, that is, enrolled in both Medicare and Medicaid. Nearly 10% of our MEPS sample are dual eligible compared to 17% reported by Walsh and colleagues using the
Medicare Current Beneficiary Survey.57
The difference may be because we excluded rural elderly living in facilities (mostly nursing homes), who are much more likely to be dual eligible beneficiaries than the community-dwelling elderly.
Dual eligible beneficiaries
are a special population known to have worse
health status, higher healthcare costs, less education, and an increased likelihood of using long term care.57
Because they are sicker and older, they are also more likely to have healthcare use. However, Medicaid enrollment was still significantly associated with greater likelihood of ED use after we controlled for other variables including health status. Thus, it appears that there are other pathways through which Medicaid impacts ED use among the rural elderly.
Another of our findings is that enrollment in Medicaid managed care is associated with lower probability of any ED use. This has been found in previous studies.45,46
There are several possible reasons that may explain this. First, those enrolled in Medicaid managed care might be healthier.58
Second, Medicaid managed care may limit enrollees' health services use. Access to care has been shown to be worse under for-profit than non-for-profit plans for Medicaid managed care enrollees.59
Third, Medicaid managed care may be superior to other health services (e.g. they may focus on providing continuity of
primary care services to enrollees), thereby keeping people healthier and reducing the likelihood of ED use
Our study found regional variation in rural elderly ED use after controlling for other variables
. Compared to the Northeast US
, the rural elderly in the West and the South had lower probability of having any ED visits. There are several possible reasons for this. First, rural residents in different regions may face different travel distance and time. Previous studies have suggested that greater
travel distance, more time spent traveling, and more difficulty for rural residents in obtaining transportation in order to receive medical care present geographic access barriers to healthcare in rural areas.8,10,13,16
Second, the geographic variation in ED use may be explained by variation in healthcare resources across different regions. Previous studies have found that in the South and West the supply of physicians and medical education capacity have not kept up with the population
An insufficient supply of physicians presents an access barrier and may result in worse health outcomes, thus increasing ED use. Another reason for the regional variation in ED use
may be variation in
access and quality of other healthcare services. For example, better primary care may lead to better health outcomes, thus lowering the likelihood of requiring any ED visits. However, this explanation seems implausible because of evidence in the literature of less supply of physicians and lower quality of care in the West and South.61–63
It should follow from this that people in the West and South should have higher ED use, which contradicts our finding.
of our findings are inconsistent with previous studies. First
, we found that more
education was associated with higher likelihood of having any ED visits. This
contradicts other studies.30,40,64–66 Second, we
failed to find a significant association between continuity of care
(as measured by having a usual source of care) and having any ED visits, as other studies did.37,38,41,67
But those studies were mostly conducted with urban populations. The rural elderly may behave differently. For instance, one explanation for the association between education and having any ED visits might be that more highly educated people are more conscious about health, and tend to seek healthcare more often when they feel sick,68–76
but because of the lack of primary care physicians in rural areas they may have to go to an ED for their “regular” healthcare. The failure to find an association between continuity of care and ED use may have occurred because the only measure of continuity of care we included was whether a person had a USC. Such a measure is likely to miss other critical information, such as how often and how effectively individuals use their usual source of care, which has been carefully examined in other studies.37,38,41,67
Unfortunately, MEPS does not provide such information.
How do our results compare to those of the only previous study of an exclusively rural sample that included whether or not there was any ED use as the dependent variable in a logistic regression model? Neither our not the West Texas
found age or gender to be statistically significant. However
, the West Texas study found better physical and mental health as measured by the SF-12 Physical and Mental Component Summary scores to be associated with less likelihood of having any ED visits. While our study did not include the SF-12, we did find a significant association for self perceived physical, but not mental, health, with people reporting better physical health having lower likelihood of at least one ED visit.
There are several limitations to our study. First, we did not include several factors that we would expect to
influence whether people had any ED visits. For example, we did not include any “supply side” information (for instance
, for a geographic area, the number of hospitals with an ED and the numbers of physicians per thousand persons). Another
important consideration for rural residents
is geographic distance and transportation. We did not include variables for them because of lack of information on distance, too many missing values for travel time to usual source of care, and lack of variance in transportation (e.g. the majority of people drive or are driven). Second, measurement error may be an issue. As MEPS interviews a single informant who reports for each household during each survey round, accuracy about household reported medical conditions and healthcare use may be of concern.35,77
In particular, the accuracy of this approach is questionable as it relates to specific individuals when a single informant reports on the mental health status of all members in each household. Third, our dependent variable, having any ED use (yes or no), is dichotomous. For a continuous dependent variable, frequent ED users might differ from non-frequent users. Fourth, there are different kinds of rurality. Some rural areas are more populous than others while some are more remote from urban areas. Previous studies have found that the elderly in remote rural areas are less likely than those in urban areas to have an ED visit while rural areas adjacent to a city are more likely to have an ED visit than those in urban areas.27,38
Thus, types of rurality may be important in determining ED use patterns. However, we could not differentiate between different kinds of rurality in the public use MEPS dataset. Fifth, the 43.5% of the study sample that resided in the Southern Census Region is 22% higher than the 35.6% for the entire US population for the 2000 Census (100 million of 281 million) and 20% higher than the 36.4% for 2006 (109 million of 299 million). We expect that this difference is due to the higher proportion of people in the Southern US than the other 3 Census Regions that reside in rural areas. Further, we do not expect that this higher proportion will distort our results. Finally, some may consider that we did not adequately control for Type I error as we tested 24
hypotheses, which has an expected 1.25 false rejections
But in a study such as ours that examines an issue for the first time, we felt it better to use the traditional significance level
of 0.05 for each test
as we would rather falsely accept a hypothesis than identify a significant factor as non-significant. Identification as non-significant in initial research could lead to important variables being excluded from future research.
In conclusion, for the rural elderly widowhood, post-high school education, Medicaid enrollment, fair/poor self perceived physical health, respiratory diseases, and heart disease were associated with higher probability of having any ED visits while living in the South and West and being enrolled in Medicaid managed care were associated with lower probability of any ED use. While Medicaid enrollees reporting other than poor physical health are more likely to have at least one ED visit than those not on Medicaid, persons on Medicaid reporting poor physical health may be less likely to have any ED visits. Policy makers and hospital administrators should consider these factors when addressing the demand for emergency care, including developing interventions to provide needed care through alternate means.