Factors Associated with the Over Utilization of the Emergency Department

Introduction

The overuse of emergency department services in hospitals has become an issue of increased concern in the past couple of decades. This concern has been exhibited by healthcare professionals, experts and analysts in the field, and laypersons alike. Consequently, a number of popular stereotypes have emerged regarding the matter of the overuse of emergency room facilities. The implicit assumptions behind these stereotypes are often misguided and rooted in perceptions that lack an accurate factual basis (LaCalle & Rabin, 2010). However, it is indeed correct that many hospital emergency departments experience an unnecessary burden in terms of caseload, and this burden could be reduced if health care delivery systems were to curb the inefficiencies that generate needless emergency room visits. This literature review will begin by examining some of the popular misconceptions concerning the overuse of emergency departments, and then proceed to analyze what the research actually shows concerning this question. Lastly, the problem of emergency department overuse will be examined within the context of Nola Bender’s theory of health promotion.

Emergency Department Overuse: The Popular Stereotypes and Misconceptions

A common misperception is that emergency department services are overused because healthcare consumers simply find it more convenient to visit an emergency room concerning routine, non-emergency, non-life threatening issues of health care and health maintenance (Buesching et al., 1985). For example, it is sometimes believed most individuals will visit emergency rooms with the expectation of receiving care more rapidly than they would by scheduling an appointment with a primary care physician (Kellermann, 1994). Yet another misperception of this kind is that emergency rooms are overburdened by patients seeking treatment for minor health issues such as common colds (Shesser, Kirsch, Smith, & Hirsch, 1991). Other stereotypes are that an excessive number of emergency room patients are seeking narcotic prescriptions, physician’s excuses for absenteeism from their place of employment, or seeking routine health maintenance care such as ordinary checkups (McNamara, Witte, & Koning, 1993). These popular misconceptions persist.

While this kind of abuse of emergency department services certainly exists, it is not a primary contributing factor to the overburdening of emergency rooms (Baker & Baker, 1994). A parallel myth is that it is mostly patients who lack health insurance who are the primary recipients of emergency department care (Ullman, Block & Stratmann, 1975). Another stereotype related to this myth is that persons lacking health insurance will utilize emergency department services simply to avoid paying their health care bills, on the assumption that emergency rooms are forbidden by legal, professional, and ethical standards from refusing to provide treatment to those lacking insurance, or the ability to pay (Stern, Weissman, & Epstein, 1991). However, no evidence exists that patients without health insurance are more likely to make use of emergency department services than those with health insurance (Mustard, Kozyrskyj, Barer, & Sheps, 1998). Research indicates that in the decade between the mid-1990s and the mid-2000s, the number of persons visiting emergency departments doubled during those ten years (Baker, Stevens, & Brook, 1994). Yet, these studies have also demonstrated that this escalation in the utilization of emergency room services has been primarily enhanced by an increase in the number of patients with health insurance, from median income socioeconomic backgrounds, and who maintain primary care physicians.

The fact that increased numbers of insured patients with relative financial stability are using emergency room services requires an explanation (Newton & Keirns, 2008). Some economists specializing in the economics of health care have attributed this increase to changes regarding the way information concerning health issues is disseminated. Specifically, economists have identified the problem of asymmetric information. According to this theory, many patients are incapable of evaluating whether a particular health issue they may experience is a matter of critical concern requiring emergency treatment. Patients do not have the medical expertise of physicians, or even less formally trained healthcare professionals, and therefore cannot make effective judgments whether a visit to an emergency department is warranted (Padgett & Brodsky, 1992). Instead, some patients will treat every symptom they experience as a potentially dire threat to their health, and proceed to visit an emergency room for the sake of prudence.

Another factor contributing to the increase in the use of emergency room services is the manner in which primary care is delivered (Meisel & Pine, 2008). Office visits to primary care physicians are typically only available during ordinary weekdays (Pasarin et al., 2006). Persons who work regular day jobs during the week, or who experience health difficulties during the evening hours or on weekends, will not be able to immediately undergo an office visit to a primary care physician. Further, even the process of scheduling an appointment can be difficult during normal off-hours. Some physicians will take emergency patients outside of normal office hours. But a person experiencing a health issue who tries to contact a primary care physician during off-hours is just as likely to be greeted by a voice mail or answering service and told to call back during regular hours or go to the emergency department of the nearest hospital if the problem is serious (Ragin et al, 2005). In other words, for many patients, emergency departments assume the role of a twenty-four-hour medical clinic.

A corresponding difficulty relating to the overuse of emergency departments is the increase in waiting times for patients, and diminished patient satisfaction with emergency room services (Grumbach, Keane, & Bindman, 1993). Yet many patients continually find visits to emergency departments to be more time-efficient than comparable visits to ordinary primary care physicians (Falik, Needleman, Wells, & Korb, 2001). The treatment of many health issues through a primary care physician involves scheduling a first appointment, then scheduling tests or further visits to specialists, followed by a waiting period for test results, and follow up appointments (Gill & Diamond, 1996). This process takes place over a matter of days, or even weeks or months in less serious cases. Additionally, the research has also found that a very high percentage of patients who visit hospital emergency departments believe themselves to be experiencing a genuine healthcare emergency (Wharam et al., 2007). The process of administering tests is much more rapid in emergency departments than it is in primary care physician’s offices. Also, emergency department personnel are among the best trained, and therefore make the best impressions on patients who return to use their services.

The costs of emergency room visits and the process of collecting payment also contribute to the increased use of emergency department services (Wehmer, 1992). Ordinary economic logic indicates that the lower the costs patients must bear for treatment, the greater the consumer demand for treatment will be (Health Management Associates, 2008). Co-payments, for example, are typically lower for treatments provided by emergency departments than they are for comparable services provided by primary care physicians’ offices (Grudzen & Brook, 2007). The costs associated with seeking treatment at a primary care physician’s office also increases according to the greater time frame associated with the provision of treatment. This may include the scheduling of additional appointments, visiting additional specialists, attending multiple testing locations, and lost income from missed time at the patient’s place of employment.

Of course, those patients who lack health insurance do have an even greater incentive to utilize the services of hospital emergency departments (Weil, 1993). As mentioned, various bits of federal and state legislation, and professional and ethical standards, prevent emergency rooms from simply refusing to provide care to the uninsured (O'Grady, K., Manning, Newhouse, & Brook, 1985). The data also indicates that hospitals are far less likely to pursue debt collection from uninsured patients that default on the payment of their medical bills. Legislation barring refusal of care to the uninsured normally does not apply to primary providers, however, and many primary care providers will indeed refuse treatment to uninsured prospective patients (Pitts, Niska, Xu, & Burt, 2008). This refusal will sometimes occur even when the patient is willing and able to pay cash for services rendered. Indeed, there are a significant number of documented cases of primary care facilities refusing to provide even emergency care to uninsured patients.

ED Overuse: Its Structural Causes and Concerns for Healthcare Professionals

Thus far, the focus of this analysis has been on the incentives provided to individuals for the overuse of emergency departments. Acknowledged difficulties of these kinds include processes of healthcare delivery, perceived quality of care, methods of payment, and knowledge imbalances between patients and physicians. However, multiple structural factors also drive the overutilization of hospital emergency rooms (Derlet & Richards, 2000). While many of the stereotypes concerning patients who utilize emergency department services are false or misplaced, it remains true that overburdened emergency rooms continue to be an increasingly difficult problem for healthcare professionals (Rask, Williams, Parker, & McNagny, 1994). Not only is the overuse of emergency departments a major contributor to the increased costs of emergency care, and healthcare in general, but these burdens have contributed to an actual reduction in the availability of care to those most in need.

The frequency of visits to hospital emergency rooms has increased by more than six hundred percent over the past half-century (Miller & Gengler, 1993). In the year 2000 alone, there were more than one hundred million emergency room visits, meaning that approximately one in three Americans sought emergency room treatment at least once during that year (Orr, Charney, Straus, & Bloom, 1991). Approximately one-third of all patients arriving at hospital emergency departments are children (Mistry, Hoffman, Yauck, & Brousseau, 2006). While unnecessary emergency room visits no doubt play a peripheral role in the overburdening of emergency departments, they are not the primary reason why these burdens have emerged (Sprivulis et al., 2006). Instead, hospital emergency rooms are overcrowded because of the increased number of people seeking treatment for serious injuries or illnesses.

What has been the source of this increase? As mentioned, hospital emergency rooms are prohibited by federal legislation from refusing care based on the ability to pay (Mortensen & Song, 2008). Consequently, emergency departments are the only consistent healthcare venues where a minimum amount of care is guaranteed (Miller, Cohen, & Rossman, 1993). However, there is no reimbursement to healthcare providers for the costs incurred by non-paying patients, and even costs associated with participants in public programs such as Medicare and Medicaid are not fully reimbursed (Ahern & McCoy, 1992). Consequently, hospitals lose tens of millions of dollars in revenue on an annual basis due to non-paying clients (Mitchell & Remmel, 1992). These losses have become problematic for hospitals to such a great degree that hundreds of hospitals and thousands of emergency departments have actually closed since the late 1990s (Saywell et al, 1992). This further reduces the availability of healthcare.

Numerous additional problems have likewise contributed to an increased reliance on emergency department services by health care consumers (Cunningham, 2006). The number of Americans lacking health insurance has grown significantly in recent decades, and fewer employers are providing health insurance as a benefit (DeLia & Cantor, 2009). While the recently enacted Affordable Care Act involves a public policy effort to extend the availability of health insurance coverage, the data indicating the degree to which this reform will reduce dependency on emergency department services by persons formerly lacking health insurance is not yet available. Also, the relaxation of rules pertaining to the amount and quality of staff a hospital must maintain in its emergency services department has motivated some hospitals, particularly in rural areas and secondary cities, to reduce the size of their staff of emergency personnel (Bolibar et al., 1996). Even some hospitals in larger cities have done the same, even as it is the emergency departments in these hospitals that are already the most overburdened (Rust, et al., 2009). Some private physicians and primary care networks have also increasingly declined to receive Medicare and Medicaid patients (American College of Emergency Physicians, 2006). Others have terminated their previous relationships with patients of these kinds.

Yet another factor impacting the problem of overburdened emergency departments is the decline of the social safety net (Friedman, Hagland, Hudson, & McNamara, 1992). Research indicates that not only is the social safety net considerably smaller than comparable systems in other Western industrialized countries, but that existing services of this kind are poorly managed, lack adequate funding, and often fail to be integrated with other public services in ways that subsequently undermine their efficiency and cost-effectiveness (McConnell, Vogt, & Smith, 2008). Needless to say, there needs to be a change in the world of healthcare. Not only have the ranks of those lacking health insurance grown in recent decades, but the degree of polarization and stratification among the layers of the socioeconomic hierarchy has also expanded dramatically (Hellinger, 1992). The number of homeless people in the United States is also estimated to be potentially as high as ten million (Pearson, Bruggman, & Haukoos, 2007). A particularly serious problem for those on the lower end of the socioeconomic strata is a lack of preventative care, including prenatal care (White-Means & Thornton, 1989). Those who are most dependent on hospital emergency departments for primary care are overwhelmingly drawn from the ranks of the poor and disadvantaged, racial minorities, children, single mothers, the homeless, the chronically unemployed, and others among the most vulnerable populations (Ionescu-Ittu et al., 2007). This is an ongoing serious problem in the United States.

Overburdened Emergency Departments and the Theory of Health Promotion

Pender, Murdaugh, and Parsons’s (2010) theory of health promotion focuses on three primary areas of healthcare delivery and patient treatment: the experiences and characteristics of the individual patient, individual awareness and perception of the relationship between behavior and health maintenance, and specific outcomes of individual behaviors. An individual’s personality traits impact their healthcare-related behaviors (Yarboro, 1990). Likewise, individuals will possess different degrees of motivation regarding their health maintenance and personal healthcare procurement issues. These differentials will also be impacted by the individual’s degree of knowledge concerning matters of health (DeSalvo, Rest, Knight, Nettleman, & Freer, 2000). The influence of nursing professionals is capable of changing individual outlooks and altering individual behaviors concerning care for one’s own health (Horrocks, Anderson, & Salisbury, 2002). The theory of health promotion model seeks to inculcate in individuals a concern for their own health maintenance, and modification of their behaviors towards the end of enhancing the overall quality of the health of patient care consumers.

An application of the theory of health promotion to the problem of the overuse of hospital emergency departments might be approached in multiple ways, and from a variety of angles (Hoot & Aronsky, 2008). The first of these is a greater emphasis on preventative healthcare (Althaus et al., 2011). Such an emphasis necessitates addressing the problem of asymmetric information (Rector, Venus, & Laine, 1999). For example, emergency room visits for serious health crises such as heart attacks and strokes might be reduced through greater efforts at reducing the causes of these issues, such as high blood pressure and high cholesterol (Stein, Harzheim, Costa, Busnello, & Rodrigues, 2002). Professional standards might also be altered in order to reduce incentives for patient reliance on emergency department services (Wilson et al., 2008). Primary care should be more readily available, and providers should be given incentives towards that end (Selby, 1997). Changes in this area might include less waiting time for appointments and greater availability of primary care physicians outside of weekday hours.

Additional reforms might include providing financial incentives for physicians to spend greater amounts of time with patients that are most in need of attention. Ultimately, it may become necessary to allow hospitals to refuse service to persons lacking critical health issues, but while referring them to primary care physicians who will become available within a reasonable amount of time in the process. Simultaneously, however, healthcare consumers need to be educated concerning when a visit to an emergency department is appropriate. Efforts of this kind must also be correlated with the provision of the necessary knowledge to patients that they will need to manage chronic health issues. Further, the reimbursement of providers for indigent care and the care of Medicare and Medicaid patients is crucial.

References

Ahern, M. & McCoy, H. (1992, Spring). Emergency room admissions: Changes during the financial tightening of the 1980s. Inquiry, 29(1), 67–79.

Althaus, F., Paroz, S., Hugli, O., Ghali, W. A., Daeppen, J-B., Peytremann-Bridevaux, I., & Bodermann, P. (2011). Effectiveness of interventions targeting frequent users of emergency departments: A systematic review. Annals of Emergency Medicine, 58(1), 41–52.

American College of Emergency Physicians (2006). Maryland talking points with Rep. Hurson—national Medicaid reforms—issues with emergency medicine. Retrieved from http://www.acep.org/advocacy.aspx?LinkIdentifier=id&id=29316&fid=1402&Mo=No&Mo=No

Baker, D., Stevens, C., & Brook, R. (1994, June 22). Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. Journal of the American Medical Association, 271(24), 1909–1912.

Baker, L., & Baker, L. (1994, Winter). Excess cost of emergency department visits for non-urgent care. Health Affirmative, 13(5), 162–171.

Bolibar, I., Balanzo, X., Armada, A., Fernandez, J., Foz, G., Sanz, E., & de la Torre, M. (1996). Impact of the primary health care reform on the use of the hospital emergency services. Med Clinician 107(8), 289–295.

Buesching, D., Jablonowski, A., Vesta, E., Dilts, W., Runge, C., Lund, J., & Porter, R. (1985, July 14). Inappropriate emergency department visits. Annals of Emergency Medicine, 14(7), 672–676.

Cunningham, P. (2006). Medicaid/SCHIP cuts and hospital emergency department use. Health Affirmative, 25(1), 127-137.

DeLia, D. & Cantor, J. (2009). Emergency department utilization and capacity. Robert Wood Johnson Foundation. Research Synthesis Report 17. Retrieved from http://www.rwjf.org/files/research/072109policysynthesis17.emergencyutilization.pdf

Derlet, R. & Richards, J. (2000). Overcrowding in the nation's emergency departments: Complex causes and disturbing effects. Annals of Emergency Medicine, 35(1), 63–68.

DeSalvo, A., Rest, S., Knight, T., Nettleman, M., & Freer, S. (2000). Patient education and emergency room visits. Clinic Performance and the Quality of Health Care, 8(1), 35–37.

Falik, M., Needleman, J., Wells, B., & Korb, J. (2001). Ambulatory care sensitive hospitalizations and emergency visits: Experiences of Medicaid patients using federally qualified health centers. Medical Care, 39(6), 551–561.

Fish Ragin, D. F., Hwang, U., Cydulka, R. K., Holson, D., Haley, L. L. Jr., Richards, C. F., Becker, B. M., & Richardson, L. D. (2005). Reasons for using the emergency department: Results of the EMPATH study. Academic Emergency Medicine, 12(12), 1158-1166.

Friedman, E., Hagland, M., Hudson, T., & McNamara, P. (1992, February 20). The sagging safety net: Emergency departments on the brink of crisis. Hospitals, 66(4), 26–40.

Gill, J. & Diamond, J. (1996). Effect of primary care referral on emergency department use: Evaluation of a statewide Medicaid program. Family Medicine, 28(3),178–182.

Grumbach, K., Keane, D., & Bindman, A. (1993, March). Primary care and public emergency department overcrowding. American Journal of Public Health, 83(3), 372–378.

Grudzen, C. & Brook, R. (2007). High-deductible health plans and emergency department use. Journal of the American Medical Association, 297(10), 1126–1127.

Health Management Associates (2008, May). Co-pays for nonemergency use of hospital emergency rooms: Cost effectiveness and feasibility analysis. Austin, Texas Health and Human Services Commission. Retrieved from http://www.hhsc.statetx.us/reports/HospitalEmergencyRoomsAnalysis_0708.pdf

Hellinger, F. (1992, Fall). Forecasts of the costs of medical care for persons with HIV: 1992-1995. Inquiry, 29(3), 356–365.

Hoot, N. & Aronsky, D. (2008). Systematic review of emergency department crowding: Causes, effects, and solutions. Annals of Emergency Medicine, 52(2), 126–136.

Horrocks, S., Anderson, E., & Salisbury C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. Boston Medical Journal, 324(7341), 819–823.

Ionescu-Ittu, R., McCusker, J., Ciampi, A., Vadeboncoeur, A.-M., Roberge, D., Larouche, D., Verbon, J., & Pineault, R. (2007). Continuity of primary care and emergency department utilization among elderly people. Canadian Medical Association Journal, 177(11), 1362–1368.

Kellermann, A. (1994, June 22). Nonurgent emergency department visits: Meeting an unmet need. Journal of the American Medical Association, 271(24), 1953–1954.

LaCalle, E. & Rabin E. (2010). Frequent users of emergency departments: The myths, the data, and the policy implications. Annals of Emergency Medicine, 56(1), 42–48.

McConnell, K., Vogt, M., & Smith, J. (2008). Impact of Medicaid cutbacks on emergency department use: The Oregon experience. Annals of Emergency Medicine, 52(6), 626–634.

McNamara P., Witte, R., & Koning, A. (1993, May 20). Patchwork access: Primary care in EDs on the rise. Hospitals, 67(10), 44–46.

Meisel, Z. & Pine, J. (2008, September 12). The allure of the one-stop shop: The real reasons why people go to the E.R. when they shouldn’t. Slate.Com. Retrieved from http://www.slate.com/articles/health_and_science/medical_examiner/2008/09/the_allure_of_the_onestop_shop.html#

Miller, M., Gengler, D. (1993, Fall). Medicaid case management: Kentucky's Patient Access and Care Program. Health Care Financial Review, 15(1), 55–69.

Miller, T., Cohen, M., & Rossman, S. (1993, Winter). Victim costs of violent crime and resulting injuries. Health Affirmative, 12(4), 186–197.

Mistry, R. D., Hoffman, R. G., Yauck, J. S., & Brousseau, D. C. (2006). Association between parental and childhood emergency department utilization. Pediatrics, 115(2),147–151.

Mitchell, T. A. & Remmel, R. J. (1992, October 21). Level of uncompensated care delivered by emergency physicians in Florida. Annals of Emergency Medicine, 21(10), 1208–1214.

Mortensen, K. & Song, P. (2008). Minding the gap: A decomposition of emergency department use by Medicaid enrollees and the uninsured. Medical Care, 46(10), 1099–1107.

Mustard, C., Kozyrskyj, A., Barer, M., & Sheps, S. (1998). Emergency department use as a component of total ambulatory care: A population perspective. Canadian Medical Association Journal, 158(1), 49–55.

Newton, M., Keirns, C., Cunningham, R., Hayward, R., & Stanley, R. (2008). Uninsured adults presenting to US emergency departments: Assumptions versus data. Journal of the American Medical Association, 300(16), 1914–1924.

O'Grady, K., Manning, W., Newhouse, J., & Brook, R. (1985, August 22). The impact of cost sharing on emergency department use. New England Journal of Medicine, 313(8), 484–490.

Orr, S., Charney, E., Straus, J., & Bloom B. (1991, March 29). Emergency room use by low income children with a regular source of health care. Medical Care, 29(3), 283–286.

Padgett, D. & Brodsky, B. (1992, November). Psychosocial factors influencing non-urgent use of the emergency room: A review of the literature and recommendations for research and improved service delivery. Social Science and Medicine, 35(9), 1189–1197.

Pasarin, M., Fernandez de Sanmamed, M., Calafell, J., Borrell, C., Rodriguez D, … Plasència, A.(2006). Reasons for attending emergency departments: People speak out. Gac Sanit, 20, 91–99.

Pearson, D., Bruggman, A., & Haukoos, J. (2007). Out-of-hospital and emergency department utilization by adult homeless patients. Annals of Emergency Medicine, 50(6), 646–652.

Pender, N., Murdaugh, C. & Parsons, M. (2010). Health promotion in nursing practice. Upper Saddle River, New Jersey: Prentice-Hall.

Pitts, S., Niska, R., Xu, J., & Burt. C. (2008, August 6). National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf

Ragin, D. F., Hwang, U., Cydulka, R. K., Holson, D., Haley, L. L. Jr., Richards, C. F., & Richardson, L. D. (2005). Reasons for using the emergency department: Results of the EMPATH Study. Academy of Emergency Medicine, 12(12), 1158–1166.

Rask, K., Williams, M., Parker, R., & McNagny, S. (1994, June 22). Obstacles predicting lack of a regular provider and delays in seeking care for patients at an urban public hospital. Journal of the American Medical Association, 271(24), 1931–1933.

Rector, T. S., Venus, P. J., & Laine, A. J. (1999). Impact of mailing information about nonurgent care on emergency department visits by Medicaid beneficiaries enrolled in managed care. American Journal of Managed Care, 5(12), 1505–1512.

Rust, G., Baltrus, P., Ye, J., Daniels, E., Quarshie, A., Boumbulian, P., & Strothers, H. (2009). Presence of a community health center and uninsured emergency department visit rates in rural counties. Journal of Rural Health, 25(1), 8–16.

Saywell, R., Nyhuis, A., Cordell, W., Crockett, C., Woods, J., & Rodman, G. (1992, January). An analysis of reimbursement for outpatient medical care in an urban hospital emergency department. American Journal of Emergency Medicine, 10(1), 8–13.

Selby, J. (1997). Cost sharing in the emergency department: Is it safe? Is it needed? New England Journal of Medicine, 336(24),1750–1751.

Shesser, R., Kirsch, T., Smith, J., Hirsch, R. (1991, July 20). An analysis of emergency department use by patients with minor illness. Annals of Emergency Medicine, 20(7), 743–748.

Sprivulis P. C., Da Silva J. A., Jacobs I. G., Frazer A. R., & Jelinek G. A. (2006). The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Medicine Journal of Australia, 184(5), 208-202.

Stein, A. T., Harzheim, E., Costa, M., Busnello, E., & Rodrigues, L. C. (2002). The relevance of continuity of care: A solution for the chaos in the emergency services. Family Practice, 19(2), 207–210.

Stern, R.,Weissman, J., Epstein, A. (1991, October 23). The emergency department as a pathway to admission for poor and high-cost patients. Journal of the American Medical Association, 266(16), 2238–2243.

Ullman, R., Block, J., & Stratmann, W. (1975, December 13). An emergency room's patients: Their characteristics and utilization of hospital services. Medical Care, 13(12), 1011–1020.

Weil, T. (1993, May 22). Clinton's health reform and emergency department volumes: A return visit. Annals of Emergency Medicine, 22(5), 852–854.

Wehmer, R. (1992, February). Let's put a stop to emergency room abuse. Texas Journal of Medicine, 88(2), 9–10.

Wharam, J. F., Landon, B. E., Galbraith, A. A., Kleinman, K. P., Soumerai, S. B., & Ross-Degnan, D. (2007). Emergency department use and subsequent hospitalizations among members of a high-deductible health plan. Journal of the American Medical Association, 297(10), 1093–1102.

White-Means, S. & Thornton, M. (1989) Nonemergency visits to hospital emergency rooms: A comparison of blacks and whites. Milbank Quarterly, 67(1), 35–57.

Wilson, A. R., Bargman, E. P., Pederson, D., Wilson, A, Garrett, N. A., Plocher, D. W., & Aillf, P. L. (2008). More preventive care, and fewer emergency room visits and prescription drugs health care utilization in a consumer-driven health plan. Benefits Quarterly, 24(1), 46–54.

Yarboro, T. (1990, February). Emergency room use by patients from the family practice of a black physician. Journal of the National Medical Association, 82(2), 93–97.