Advocates for Evidence-Based Health Policy Speakers
Planes, Trains, and Ambulances
Freestanding emergency departments (FSED) are defined as “facilities that are structurally separate and distinct from a hospital and provide emergency care”. Over the past several years, the number of freestanding emergency departments has grown exponentially. With this growth come many questions surrounding the utility of FSEDs and their role in access to health care.
Recognizing that the emergency department plays a critical part in the health of underserved populations, researchers sought to analyze the role of FSEDs in access to care in this population. Carlson, et al performed a geospatial analysis comparing FSEDs and hospital-based emergency departments (HBEDs) to public transportation across three major metropolitan areas. Utilizing U.S. Census data, public transportation maps, and HBED and FSED locations, they calculated the distance from each HBED and FSED to public transportation.
The analysis found that FSEDs are located farther from public transportation than HBEDs. The median distance from a FSED to public transit was greater compared to HBEDs across all three locations – by 0.2, 1.0, and 1.6 miles in Denver, Houston, and Cleveland, respectively.
It is unlikely that FSEDs increase access to care among underserved populations. Presuming that underserved patients are more likely to utilize public transportation to access medical care compared to people with their own vehicles, it is reasonable to further assume that the increased distance of FSED from public transportation limits access to care. Additionally, the authors note that many FSEDs operate independently from hospitals, are not strictly subject to the EMTALA mandate, and may not accept Medicare and Medicaid reimbursement, potentially exacerbating financial barriers for these patients . For those who elect care elsewhere after learning that their insurance is not accepted, delays in care may ensue.
Although many assert that FSEDs have the potential to decrease overcrowding at HBEDs by creating additional sources of emergency care, the evidence to date does not bear that out. Instead of decreasing overcrowding at HBEDs, FSEDs simply provide an additional access point to the health care system for those whose insurance is accepted.
This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Emergency Medicine Residents’ Association. It is written by Caitlin Farrell DO, MPH. She is an emergency medicine resident at Baystate Medical Center.
Abstract
INTRODUCTION: Emergency departments (ED) are an important source of care for underserved populations and represent a significant part of the social safety net. In order to explore the effect of freestanding emergency departments (FSED) on access to care for urban underserved populations, we performed a geospatial analysis comparing the proximity of FSEDs and hospital EDs to public transit lines in three United States (U.S.) metropolitan areas: Houston, Denver, and Cleveland.
METHODS: We used publicly available U.S. Census data, public transportation maps obtained from regional transit authorities, and geocoded FSED and hospital ED locations. Euclidean distance from each FSED and hospital ED to the nearest public transit line was calculated in ArcGIS. We calculated the odds ratio (OR) of an FSED, relative to a hospital ED, being located within 0.5 miles (mi) of a public transit line using logistic regression, adjusting for population density and median household income and with error clustered at the metropolitan statistical area (MSA) level.
RESULTS: The median distance from FSEDs to public transit lines was significantly greater than from hospital EDs across all three markets. In Houston, Denver, and Cleveland, the median distance between FSEDs and public transit lines was greater than from hospital EDs by 1.0 mi, 0.2 mi, and 1.6 mi, respectively. The OR of a public transit line being located within 0.5 mi of an FSED, as compared with a hospital ED, across all three MSAs was 0.21 (95% confidence interval [CI], 0.13-0.34) unadjusted and 0.20 (95% CI, 0.11-0.40) adjusted for population density and median household income.
CONCLUSION: In comparison with hospital EDs, FSEDs are located farther from public transit lines and are less likely to be within walking distance of public transportation. These findings suggest that FSEDs are unlikely to directly increase access to care for patients without private means of transportation. Further research is necessary to explore both the direct and indirect impact of FSEDs on access to care, potentially through effects on hospital ED crowding and overall healthcare expenditures, as well as the ultimate role and responsibility of FSEDs in improving access to care for underserved populations.
PMID: 31123548
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