Newton Manya F, Keirns Carla C, Cunningham Rebecca, Hayward Rodney A, Stanley Rachel
Robert Wood Johnson Clinical Scholars Program, University of Michigan School of Medicine, 1150 W Medical Center Dr, 6312 Medical Science Bldg 1, Ann Arbor, MI 48109-5604, USA.
JAMA. 2008 Oct 22;300(16):1914-24. doi: 10.1001/jama.300.16.1914.
Emergency departments (EDs) are experiencing increased patient volumes and serve as a source of care of last resort for uninsured patients. Common assumptions about the effect of uninsured patients on the ED often drive policy solutions.
To compare common unsupported statements about uninsured patients presenting to the ED with the best available evidence on the topic.
OVID search of MEDLINE and MEDLINE in-process citations from 1950 through September 19, 2008, using the terms (Emergency Medical Services OR Emergency Service, Hospital OR emergency department.mp OR emergency medicine.mp OR Emergency Medicine) AND (uninsured.mp OR medically uninsured OR uncompensated care OR indigent.mp OR uncompensated care.mp OR medical indigency).
Of 526 articles identified, 127 (24%) met inclusion/exclusion criteria. Articles were included if they focused on the medical and surgical care of adult (aged 18 to <65 years) uninsured patients in emergency settings. Excluded articles involved pediatric or geriatric populations, psychiatric and dental illnesses, and non-patient care issues.
Statements about uninsured patients presenting for emergency care that appeared without citation or that were not based on data provided in the articles were identified using a qualitative descriptive approach based in grounded theory. Each assumption was then addressed separately in searches for supporting data in national data sets, administrative data, and peer-reviewed literature.
Among the 127 identified articles, 53 had at least 1 assumption about uninsured ED patients, with a mean of 3 assumptions per article. Common assumptions supported by the evidence include assumptions that increasing numbers of uninsured patients present to the ED and that uninsured patients lack access to primary care. Available data support the statement that care in the ED is more expensive than office-based care when appropriate, but this is true for all ED users, insured and uninsured. Available data do not support assumptions that uninsured patients are a primary cause of ED overcrowding, present with less acute conditions than insured patients, or seek ED care primarily for convenience.
Some common assumptions regarding uninsured patients and their use of the ED are not well supported by current data.
急诊科接待的患者数量不断增加，并且是未参保患者的最后求助医疗场所。关于未参保患者对急诊科影响的常见假设常常推动政策解决方案的出台。
将有关前往急诊科就诊的未参保患者的常见无依据说法与该主题的最佳现有证据进行比较。
通过OVID检索1950年至2008年9月19日的MEDLINE及MEDLINE在研文献，检索词为（“紧急医疗服务”或“医院急诊服务”或“急诊科.mp”或“急诊医学.mp”或“急诊医学”）以及（“未参保.mp”或“医疗未参保”或“无偿医疗服务”或“贫困.mp”或“无偿医疗服务.mp”或“医疗贫困”）。
在识别出的526篇文章中，127篇（24%）符合纳入/排除标准。如果文章聚焦于急诊环境中成年（18至<65岁）未参保患者的医疗和外科护理，则予以纳入。排除的文章涉及儿科或老年人群、精神疾病和牙科疾病以及非患者护理问题。
采用基于扎根理论的定性描述方法，识别出那些未加引用或并非基于文章中提供的数据而出现的有关未参保患者寻求急诊护理的说法。然后，针对每个假设分别在国家数据集、行政数据和同行评审文献中搜索支持数据。
在127篇识别出的文章中，53篇至少有1条关于急诊科未参保患者的假设，每篇文章平均有3条假设。证据支持的常见假设包括：前往急诊科就诊的未参保患者数量不断增加，以及未参保患者无法获得初级医疗服务。现有数据支持这样的说法：在适当情况下，急诊科的护理比门诊护理费用更高，但这对所有急诊科使用者都适用，无论其是否参保。现有数据不支持以下假设：未参保患者是急诊科过度拥挤的主要原因、与参保患者相比病情较轻，或主要为了方便而寻求急诊科护理。
目前的数据并未充分支持一些关于未参保患者及其使用急诊科情况的常见假设。
