Clearly, many ED visits result from lack of timely access which is especially prevalent on nights and weekends. In fact, other studies have shown that the ED is not only the venue of choice at such times, but often the only available site of care for all patients regardless of age, income level or insurance status. To quote the recent RAND study (“The Evolving Role of Emergency Departments in the United States”, Morganti et al, RAND Health, 2013): “Data from the Community Tracking Study indicate that most ambulatory patients do not use EDs for the sake of convenience. Rather, they seek care in EDs because they perceive no viable alternative exists, or because a health care provider sent them there.”
Primary care access is obviously related to the continuing (and worsening) shortage of primary care physicians in general, their limited “after hours” availability, and their unwillingness to participate in Medicaid programs in the first place.

On the subject of patient perception of severity of illness, there is plainly significant and largely unquantifiable variability in function of general educational level, degree of medical sophistication, and personal behavioral components.

As to “ethnicity/cultural issues”, while these may be operant to some degree, their potential role is difficult to analyze due to numerous possible confounding influences and are, in any event, likely of secondary importance compared to the principal barriers otherwise identified. A recent study (Hong R et al, The emergency department for routine healthcare: Race/ethnicity, socioeconomic status, and perceptual factors, Journal of Emergency Medicine, Vol 32, No 2, February 2007) found that after controlling for insurance status, income, employment status and education, neither race nor ethnicity remained a strong predictor of routine ED use. The authors note, “Race/ethnicity-based disparities in routine ED use were due to the confounding effects of socioeconomic status.”

5. What percentage of non-emergent patients use the ED as a matter of convenience/”first stop” to address their health needs?

This answer harks back to the factors cited in previous questions. In a major study by the New England Healthcare Institute (“A Matter of Urgency: Reducing Emergency Department Overuse”; A NEHI Research Brief, March 2010) the authors note that “ED overuse spans the entire population, irrespective of insurance status or age.” Elsewhere, Weber’s analysis (Weber EJ et al, Are the uninsured responsible for the increase in emergency department visits in the United States? Annals of Emergency Medicine, 2008 Aug: 52 (2): 108-115) demonstrated that the increasing rates of ED utilization have resulted from disproportionate increased visits by the insured, and that even having a usual source of care other than the ED made such patients actually more likely to utilize the ED as a point of care.