Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Ann Emerg Med. 2011 Sep;58(3):225-234.e1. doi: 10.1016/j.annemergmed.2011.02.020. Epub 2011 May 12.
Health care reform in Massachusetts improved access to health insurance, but the extent to which reform affected utilization of the emergency department (ED) for conditions potentially amenable to primary care is unclear. Our objective is to determine the relationship between health reform and ED use for low-severity conditions.
We studied ED visits, using a convenience sample of 11 Massachusetts hospitals for identical 9-month periods before and after health care reform legislation was implemented in 2006. Individuals most affected by the health reform law (the uninsured and low-income populations covered by the publicly subsidized insurance products) were compared with individuals unlikely to be affected by the legislation (those with Medicare or private insurance). Our main outcome measure was the rate of overall and low-severity ED visits for the study population and the comparison population during the period before and after health reform implementation.
Total visits increased from 424,878 in 2006 to 442,102 in 2008. Low-severity visits among publicly subsidized or uninsured patients decreased from 43.8% to 41.2% of total visits for that group (difference=2.6%; 95% confidence interval [CI] 2.25% to 2.85%), whereas low-severity visits for privately insured and Medicare patients decreased from 35.7% to 34.9% of total visits for that group (difference=0.8%; 95% CI 0.62% to 0.98%), for a difference in differences of 1.8% (95% CI 1.7% to 1.9%).
Although overall ED volume continues to increase, Massachusetts health reform was associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform. Our findings suggest that access to health insurance is only one of a multitude of factors affecting utilization of the ED.
马萨诸塞州的医疗改革改善了医疗保险的可及性，但改革对急诊室（ED）用于初级保健可治疗的疾病的利用程度尚不清楚。我们的目的是确定医疗改革与 ED 用于低严重程度疾病的使用之间的关系。
我们使用马萨诸塞州 11 家医院的便利样本，研究了 ED 就诊情况，在 2006 年实施医疗保健改革法案前后，对相同的 9 个月时间段进行了研究。受医疗改革法影响最大的个人（未参保和由公共补贴保险产品覆盖的低收入人群）与不太可能受立法影响的个人（有医疗保险或私人保险的人）进行了比较。我们的主要观察指标是研究人群和比较人群在医疗改革实施前后的总 ED 就诊率和低严重程度 ED 就诊率。
总就诊人数从 2006 年的 424878 人增加到 2008 年的 442102 人。在接受公共补贴或无保险的患者中，低严重程度就诊率从该组就诊总数的 43.8%降至 41.2%（差异为 2.6%；95%置信区间[CI]为 2.25%至 2.85%），而私人保险和医疗保险患者的低严重程度就诊率从该组就诊总数的 35.7%降至 34.9%（差异为 0.8%；95%CI 为 0.62%至 0.98%），差异为 1.8%（95%CI 为 1.7%至 1.9%）。
尽管 ED 总就诊量持续增加，但马萨诸塞州的医疗改革与受改革影响最大的人群中低严重程度就诊率的小但具有统计学意义的下降相关，而与不太可能受改革影响的人群的比较人群相比。我们的研究结果表明，获得医疗保险只是影响 ED 使用的众多因素之一。
