The European Journal of Public Health Advance Access originally published online on January 27, 2007
The European Journal of Public Health 2007 17(5):497-502; doi:10.1093/eurpub/ckl268
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Immigrant Health |
Motivation and relevance of emergency room visits among immigrants and patients of Danish origin
Marie Norredam1, Anna Mygind1, Anette Sonne Nielsen1, Jens Bagger2 and Allan Krasnik1
1 Department of Health Services Research, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
2 Emergency Department, Amager Hospital, Copenhagen, Denmark
Correspondence: Marie Norredam, MD, Department of Health Services Research, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 15, P.O. Box 2099, 1014 Copenhagen K, Denmark, tel.: + 45 3532 7630, fax: + 45 3532 7629
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Abstract |
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Background: We investigated the extent to which immigrants and patients of Danish origin have different motivations for seeking emergency room (ER) treatment, and differences in the relevance of their claims. Methods: Data were obtained from a questionnaire survey of walk-in patients and their caregivers at four Copenhagen ERs. The patient survey was available in nine languages, and addressed patient-identified reasons for using the ER. Caregivers were asked if the claim was appropriate to the ER. 3809 patients and 3905 caregivers responded. The response rate among patients was 54%. Only questionnaires in which both patient and caregiver had responded, and in which data on the patient's nationality were available, were included in the analyses (n = 3426). The effect of region of origin was examined using bivariate, stratified analyses and tested for independence. Results: More among immigrant patients than among patients of Danish origin had considered contacting a primary caregiver before visiting the ER, and more immigrants reported going to the ER because they could not contact a general practitioner, or could not explain their problem on the telephone. Compared to immigrants, more patients of Danish origin explained that the ER was most relevant to their need. A higher proportion of claims among immigrants were seen by caregivers as not being appropriate to the ER. Conclusion: Migrants have more irrelevant ER claims, presumably because of barriers in access to primary care. Access to primary care should be facilitated for these groups. Alternatively, ERs could include primary care activities as part of their services.
Keywords: access, emergency, immigrants, primary care
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Introduction |
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UN estimates show an increase in migrants worldwide from 155 million in 1990 to 191 million in 2005.1 In 2005, roughly 60% of all migrants lived in developed countries, but came from developing countries. Europe hosted 34% of all migrants in 2005. In Denmark, 8.4% of the population currently consists of first- and second-generation immigrants, nearly two-third of whom come from developing countries.2
Equity in access to health care is crucial to ensure that immigrants have the possibility of attaining the same state of mental and physical well-being as host populations. We employ WHO's definition of equity in access to health care as ‘equity in access when needs are equal’.3 This definition implies that patients preferably have access to the most relevant services for their specific needs, as this will ensure the most optimal treatment.
Access to health care services has often been investigated by measuring utilization of services. Consequently, studies of immigrants’ use of ER services have mainly focused on differences in usage rates compared to host populations. Differences in usage rates of immigrants and ethnic minorities have been reported in the United States4–6 as well as in subsidized health care systems such as in Canada and Sweden.7,8 Differences in the latter two studies, however, disappeared after controlling for socioeconomic status and self-perceived health. In a previous study, we found that some immigrant groups in Denmark (those born in Somalia, Turkey and the former Yugoslavia) had 30–50% higher utilization rates of ER services compared to the residents of Danish origin, after controlling for age, gender and income.9 Consequently, we wanted to study the factors motivating immigrants’ ER visits.
Several predictors of ER usage in the general population have already been identified.6,10–13 In addition, immigrants may experience linguistic and cultural barriers to accessing primary care, including uncertainty concerning how to navigate in the health care systems of host countries. This may result in higher ER use for some immigrants.
In the general population, ER usage has been rising in several countries.6,14 Simultaneously, several studies have shown that one-third to two-third of ER patients present non-urgent problems that could have been handled appropriately in primary care.10,14–16 Non-urgent ER claims are a source of frustration for ER caretakers and administrators because they may lead to higher expenses, crowding and treatment delays. Consequently, there is a wish to identify predictors of ER use of irrelevant claims.
Citizens in Denmark are entitled to free primary care services from their general practitioner who provides free primary care services and serves as their primary caretaker and gatekeeper to secondary health care. In case of an emergency there are three main options for seeking health care: (1) one's own general practitioner (daytime only), (2) an emergency treatment service run by the general practitioners in the area or (3) hospital-based ER services. In central Copenhagen there are four ERs which are all open for direct access on a 24-h basis.
Our hypothesis was that some immigrants would more frequently choose the ER compared to patients of Danish origin, due to barriers in access to primary care, and that caregivers would consequently find immigrants’ claims less relevant compared to the claims of patients of Danish origin. Our research questions were therefore as follows:
- Do immigrants and patients of Danish origin differ in their motivation for seeking ER treatment?
- Are there any differences between immigrants and patients of Danish origin as to the relevance of their ER claims?
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Methods |
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Design and instruments
The study was based on data from a questionnaire survey of walk-in patients and their caregivers at four ERs. We used one questionnaire for ER patients and one for their ER caregivers. The patient survey was divided into two parts. The first part concerned patient-identified reasons for using the ER instead of other services, including how acutely the patients defined their needs. The second part concerned satisfaction with ER services; the results are not included in this article. Caregivers were asked whether the complaint was relevant in an ER context, and whether the patient was hospitalized.
The patient questionnaire was available in nine languages: Danish, English, French, Arabic, Farsi, Serbo-Croatian, Turkish, Somali and Urdu. It was developed in Danish, subsequently translated into the appropriate language by one translator, and then translated back into Danish by a different translator to ensure validity. Inconsistencies were cleared in dialogue with both translators.
The survey was distributed during three separate weeks: one in September 2004, one in January 2005 and one in May 2005. This was done to take seasonal variations in morbidity patterns into account. The survey was distributed during all shifts throughout those 3 weeks.
Sampling
The study took place at the ERs of all four hospitals with open ER access in the Copenhagen Hospital Cooperation. The questionnaire was answered by 3809 ambulatory patients over three separate weeks; during that period, 7109 ambulatory patients came to the ER, amounting to a response rate of 54%. A total of 3905 responses from caretakers were obtained. In analysing the data, we used only those questionnaires where both patient and caregiver had responded. This amounted to 3585 cases. Questionnaires with missing data on the patient's country of origin were excluded. This was the case for 159 questionnaires. Our final analysis was therefore based on 3426 questionnaires.
Procedure
The questionnaire was given to all walk-in patients by the secretary or nurse who registered them in the ER. Patients were asked to fill out the first part of the questionnaire in the waiting room, prior to treatment, and the second part after treatment, but before leaving the ER. The questionnaire was collected in a sealed box before the patient left the ER. The secretary provided caregivers with a questionnaire corresponding to the same patient. Corresponding questionnaires were identified by matching serial numbers.
Analysis
All data were analysed by SAS. We analysed for bivariate associations in stratified tables, and tested for independence using the chi-square test. Patient respondents were defined as being of non-Danish origin if they themselves, as well as both parents, were born abroad (first-generation), or if they were born in Denmark to two parents born abroad (second-generation). Patients were divided into groups of origin according to their own country of birth, or—if own country of birth was Denmark—their mother's country of birth. We divided respondents into the following four groups based on region of origin: Danish (n = 2878), Western (n = 119), Middle Eastern (n = 289) and other non-Western (n = 140). Western and Middle Eastern categories were defined according to WHO guidelines.17 We included patients in all age groups. Parents or others accompanying minor patients were asked to answer the questionnaire on behalf of the patient.
Missing observations were analysed for all outcome variables. For most outcome questions, missing observations accounted for 5–20% of all answers. These were evenly distributed among the different groups of foreign origin apart from the Middle Eastern region, which had a slightly elevated number of missing observations for all questions. As this was a general finding for all questions, the higher number of missing observations is most likely not related to problems in interpreting the different questions but, rather, to general problems for this group, including language barriers. The exact amount of missing data for the outcome in question is reported in the tables or the results section.
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Results |
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Table 1 shows the demographic characteristics of the patient respondents, distributed by region of origin. Socioeconomic data are shown only for respondents
15 years. Caregivers (n = 3426) were divided into three groups according to professional background: nurses (5%), interns (43%) and specialized doctors, or residents (37%) (18% lacked information on professional background).
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Patient respondents were first asked if they had considered contacting their general practitioner before seeking treatment at the ER. We found 28% of patients of Danish origin, 40% of patients of Western origin, 42% of patients of Middle Eastern origin and 38% of patients of other non-Western origin had considered this (P < 0.01). We also asked if patients had considered contacting the emergency treatment service before coming to the ER. We found 14% of patients of Danish origin, 15% of patients of Western origin, 23% of patients of Middle Eastern origin and 18% of patients of other non-Western origin had considered this (P < 0.01). Consequently, in all groups of foreign origin, more respondents had considered contacting primary caregivers before going to the ER, compared to the patients of Danish origin.
Secondly, we asked patients about their primary reason for using the ER. The following options were given: (a) ‘I could not get in contact with a general practitioner’; (b) ‘The ER is most relevant to my need’ or (c) ‘I was referred by a primary caregiver’. Table 2 shows patient responses distributed by geographical origin, and stratified by socioeconomic position (using education as a proxy hereof). Among all respondents, 13% used the ER because they were unable to contact a general practitioner; 63% visited the ER because it was most relevant to their need, and 24% had been referred by a primary caregiver. When looking at the groups of origin, our figures showed that immigrant ER visits were more often precipitated by an inability to contact a general practitioner. In contrast, more patients of Danish origin indicated that the ER was most appropriate to their needs, compared to all immigrant groups. There were virtually no differences between these patients concerning how many had been referred to the ER by a primary caregiver. We stratified our results by socioeconomic position using number of school years, further education and income as proxies. Table 2 shows that stratifying by further education did not affect the differences in primary reasons for using the ER between patients of foreign and Danish origin. This was also the case when stratifying by number of school years and income (data not shown).
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Thirdly, patient respondents were asked if there were any additional reasons why they went to the ER. This was a supplementary question and only about 50% of respondents answered. The following options were given: (1) ‘I generally prefer the ER’; (2) ‘It was difficult for me to explain my problem on the telephone’; (3) ‘I live outside Copenhagen, but I need help here’ or (4) ‘The ER provides more specialist treatment’. We found 42% of patients of Danish origin, 27% of patients of Western origin, 57% of patients of Middle Eastern origin and 68% of patients of other non-Western origin generally preferred the ER (P < 0.01); 17% of patients of Danish origin, 26% of patients of Western origin, 44% of patients of Middle Eastern origin and 39% of patients of other non-Western origin had difficulties explaining their problem by phone and therefore went to the ER (P < 0.01); 18% of patients of Danish origin, 31% of patients of Western origin, 22% of patients of Middle Eastern origin and 37% of patients of other non-Western origin answered that they went to the ER because they lived outside Copenhagen and therefore could not visit their normal primary caregiver (P < 0.01). Finally, we found that 73% of patients of Danish origin, 78% of patients of Western origin, 82% of patients of Middle Eastern origin and 92% of patients of other non-Western origin went to the ER to receive specialist treatment (P < 0.01). All results were stratified by education. This did not affect the distribution of additional reasons for using the ER between patients of foreign origin and those of Danish origin.
Respondents were also asked how acutely they defined their need for help. More patients from Middle Eastern regions (63%) and of other non-Western origin (52%) responded that they needed acute help (<1 h), compared to patients of Danish (24%) and other Western origin (27%). These differences were significant (P < 0.01).
Caregivers reported that 21% of patients’ visits were not relevant in the ER. One-third of these did not warrant medical attention at all, while two-thirds were relevant in the health system but not relevant in an ER context. Significant differences according to patients’ geographical origins were found: 19% of visits of patients of Danish origin were deemed not relevant—compared to 30% of patients of Western origin, 33% of patients of Middle Eastern origin and 40% of patients of other non-Western origin (P < 0.01). As shown in table 3, we stratified this result by primary reason for using the ER. The table shows that the relevance of the ER visit was correlated with region of origin for all reasons for visiting the ER (though not significantly among those who came because they could not contact a general practitioner). The table also shows that most visits were considered irrelevant among those who could not contact their primary caregiver (except ‘other non-Western’): 33% versus 18% and 21% in the total (P < 0.01).
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Discussion |
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This study has several limitations. First, our results showed relatively identical outcomes for all immigrant groups according to region of origin, compared to the patients of Danish origin. This might have been because we did not refine our categories into more precise geographical regions, which was not possible due to the low number of immigrant participants. Secondly, we decided to include both first- and second-generation immigrants as only one group in our analyses. As a result, we may be missing important differences between first- and second-generation migrants. However, as many second-generation immigrants are minors, in many cases their questionnaire was filled out by their accompanying parent, thus reflecting the attitudes and behaviour of the parent. Thirdly, we included only data from ERs in central Copenhagen, where relative ER proximity is high compared to the rest of the country. This might influence the choice of ER as the primary choice in case of emergency; however, it is unclear whether the effect of distance would differ between patients of Danish origin and immigrants. Fourthly, the response rate was relatively low in the study (54%). The dropout may be due to different reasons. Being an ER patient is not the most optimal situation for responding to a questionnaire survey: patients may be interrupted in the waiting room before they are able to complete the questionnaire; some patients may be in pain or worried about their complaint; accordingly, they may be unable or unwilling to respond. This may mean that those who answered the survey were more likely to have minor complaints, which could be defined as irrelevant by caregivers. There is, however, no reason to believe that this would differ between patients of Danish origin and immigrants. Moreover, it is possible that less integrated immigrants were more unlikely to answer the questionnaire. This might underestimate the true magnitude of the communication problems that are identified in this study. Finally, it would have been relevant to include questions about the length of time that immigrants had lived in Denmark, as this could have bearing on immigrants’ degree of integration in the Danish society and thus on their communication skills. However, this was not included in order to reduce the complexity and length of the questionnaire. The stay in the ER waiting room for a patient may be short and we wished to try to ensure a high response rate by making the questionnaire relatively short and simple to answer for all respondents. It should also be mentioned that ERs are open to all groups of immigrants in Denmark, including asylum seekers and undocumented immigrants. The majority of asylum seekers, however, live in asylum centres outside the city of Copenhagen and few are therefore likely to use the ERs included in the study. The number of undocumented immigrants is unknown but is often estimated as being relatively low compared to many other European countries.
We hypothesized that immigrants and patients of Danish origin differed in their motivation for seeking ER treatment. Our findings showed that immigrants, in particular, had considered contacting a primary caregiver before visiting the ER, compared to the patients of Danish origin. Also, more immigrants sought treatment at the ER because they could not contact a general practitioner (including not being able to explain their problem on the telephone), whereas patients of Danish origin more often reported that the ER was most relevant to their need. Other studies of the general population have identified medical necessity as the principal reason for seeking ER treatment.10,18
Interestingly, our findings were identical across regions of origin for immigrants compared to patients of Danish origin. Immigrants’ motivation for seeking ER therefore seems to be related to migration status rather than ethnicity as defined by region of origin. Being an immigrant—irrespective of region of origin—may hamper contact with the health care system in several ways. Communication between patients and caregivers may be complicated by linguistic barriers. In an American study of access barriers to primary care for Latino children, parents cited language problems as the single most common barrier.19 Another American study found that non-English speaking patients with ‘only’-English-speaking primary health caregivers were more likely to use the ER.20
Being a newcomer to the Danish society also implies lack of knowledge about the functions of the health care system. Immigrants may come from places with different health care structures or few health care facilities. Immigrants arriving in Denmark are asylum seekers, quota refugees, labour migrants, students or family reunified. Asylum seekers usually live in centres where access to primary care is part of an on-site alternative health care system provided as long as they have not received permission to stay in the country. This means that they do not become acquainted with the Danish health care system before becoming Danish residents served by this system. Immigrants in the latter four groups receive no systematic introduction by authorities, but have to rely on schools, employers, friends and family for an introduction to the Danish health care system. Access to primary care could be facilitated if all newcomers were systematically introduced to the functions of the health care system in Denmark.
We also hypothesized that there were differences between immigrants and patients of Danish origin as to the relevance of their claims as defined by their caregivers. Our findings showed that caregivers evaluated an especially high proportion among the immigrants as being irrelevant (30–40%) compared to the proportion among patients of Danish origin (19%). Predictors of irrelevant ER visits have been investigated in relation to ER overcrowding and capacity discussions. However, to date, studies have not documented migration status as a predictor of irrelevant ER visits. We attribute the higher percentage of irrelevant visits among immigrants to the fact that they experience more barriers to access to primary care. To avoid irrelevant ER visits among immigrants, access to primary care should be facilitated to these groups. One possible improvement could include more open hours in general practice to bypass the problems of telephone bookings. A more radical reform would be to establish special primary care clinics open for direct access in the daytime in communities characterised by many immigrants. Alternatively, ERs could expand their activities to include more primary care services. Indeed, it has been shown that employing general practitioners in ERs to manage patients with primary care needs resulted in reduced rates of investigations, prescriptions and referrals.21 Contact problems in primary care are not found to be significant only among immigrants. Other studies have shown that ER visits, in general, are sometimes motivated by dissatisfaction with, or distrust of primary caregivers, including difficulties regarding scheduling appointments and contacting primary caregivers by telephone.22,23 Thus, the findings of our study might serve as the basis for general initiatives to improve access to relevant primary health care for the population at large.
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Acknowledgements |
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The study was supported by the Health Insurance Fund and the Copenhagen Hospital Cooperation. The study was performed in cooperation with the four ERs under Copenhagen Hospital Cooperation: Amager Hospital, Hvidovre Hospital, Bispebjerg Hospital and Frederiksberg Hospital. Special thanks to Bente Dich, Karin Marker, Joan Mortensen, Poul Mossin, Lene Tanderup and Inge-Lise Willumsen for serving as the contact persons responsible for data collection in the ER.
Conflict of interest: None declared.
Key points
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References |
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