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Inappropriate ER visits may stem from social rather than medical needs

The problem of emergency department (ED) overuse and inappropriate use and their associated costs is commonly addressed by trying to improve access to primary medical care at sites outside the ED setting. Although access to medical care is a critical dimension of the problem, a focus on access as the sole solution to inappropriate ED use may obscure other, perhaps equally relevant issues from consideration, explains Ruth E. Malone, R.N., Ph.D., of the Institute for Health Policy Studies, University of California, San Francisco. This is because heavy ED users (four or more ED visits a year) typically have complex, chronic, and multifaceted psychosocial and/or economic problems in addition to their medical problems.

With support from the Agency for Health Care Policy and Research (HS08412), Dr. Malone conducted a 1-year ethnographic study of two inner city hospital EDs, interviewing both heavy ED users and ED clinicians to provide an in-depth look at this issue. At least 70 percent of the heavy ED users were homeless and/or sufficiently poor or disabled to qualify for some form of public assistance. A majority either had no family or were estranged from their families, and most suffered from one or more chronic illnesses, such as alcoholism, opiate addiction, diabetes, hypertension, chronic pulmonary diseases, and/or mental disorders.

Patient interviews revealed that for many, the primary reasons for their ED visits were not medical. Instead, their medical problems represented a way to gain access to other kinds of low-tech care, including rest, shelter, safety, showers, food, clothing, and social interaction. The ED historically has always had a dual function, providing high-tech lifesaving measures while serving in a symbolic and practical role as "almshouse"—the caregiver of last resort for those who have nowhere else to go. By failing to address the ED's hidden role as public almshouse, we may inadvertently provide incentives to medicalize heavy ED users' complex social problems and efforts to contain costs.

See "Whither the almshouse? Overutilization and the role of the emergency department," by Dr. Malone in the October 1998 Journal of Health Politics, Policy and Law 23(5), pp. 795-832.

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