Malone R E
University of California, San Francisco, USA.
J Health Polit Policy Law. 1998 Oct;23(5):795-832. doi: 10.1215/03616878-23-5-795.
The problem of emergency department (ED) overutilization or "inappropriate" utilization is commonly conceptualized in terms of inadequate access to appropriate primary medical care. Although medical care access is a critical issue, a focus on increased access to medical care as the sole solution to "inappropriate" ED utilization may obscure other, perhaps equally relevant, issues from consideration. This article reports findings from an ethnographic study focusing on heavy users (HUs) of EDs in two inner-city hospitals. Drawing on fieldwork and on interviews with HU patients and ED clinicians, I argue that the emergence of heavy ED utilization as both a clinical and policy problem is a function not merely of unmet medical care needs for individuals, but of "almshouse" needs in a changing health care context. The emergence of ED overutilization as a problem occurs in the context of market forces that are contributing to shifts in the role of EDs and in the moral boundaries of accepted ED practice. If the problem of heavy ED use is more broadly conceptualized in terms of this role shift, not solely in terms of medical care access, a different set of issues and priorities for research, policy, and clinical practice emerges.
急诊科（ED）过度使用或“不适当”使用的问题通常被认为是由于难以获得适当的初级医疗保健服务。尽管医疗保健服务的可及性是一个关键问题，但将增加医疗保健服务的可及性作为解决“不适当”的急诊科使用问题的唯一办法，可能会使其他或许同样相关的问题得不到考虑。本文报告了一项人种志研究的结果，该研究聚焦于两家市中心医院急诊科的频繁使用者（HU）。基于实地调查以及对频繁使用者患者和急诊科临床医生的访谈，我认为急诊科过度使用作为一个临床和政策问题的出现，不仅是因为个人的医疗保健需求未得到满足，还因为在不断变化的医疗保健环境中的“救济院”需求。急诊科过度使用作为一个问题的出现，是在市场力量导致急诊科角色转变以及公认的急诊科医疗行为道德界限变化的背景下发生的。如果将频繁使用急诊科的问题更广泛地从这种角色转变的角度来理解，而不仅仅从医疗保健服务的可及性角度来理解，那么就会出现一系列不同的研究、政策和临床实践问题及优先事项。
