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108 Urgences KCE reports vol. 19B
Publication
Data
Selby et al
NEJM-1996-
USA.
MESH-terms Objective Planning Conclusion Material/Methods Results / Comments Comments/Discussion
Co-payment
and
emergencyuse.(copa).
Effect of a copayment
on the
use of ED in a
HMO.
Randomised and
controlled
prospective
trial.
A co-payment
for the use of a
Ed was
associated with
a decline of
about 15% in
the use of ED,
mostly among
inappropriate
users.
After
adjustment for
social
parameters this
study confirms
that the
selective use of
small copayments
can
safely reduce ED
use among
people through
employers
healthinsuredred.
Comparisons of ED use one yr
before and after the institution of
a co-payment.
Target is the copa-group(25-35
usd) of a HMO of 20 computer
companies.(who already paid 5-
10 usd for outpatient use.)
2 control grps:
Random sampling in general
population grp, stratified
according to age, sex, area,
use of ED.
Random sampling in a contgrp
of similar computer
companies that didnÊt
institute copa. Same
stratification as ctrl 1 group.
4 categories of care(urgent, ED,
paediatric and adult offices)
Use of ED was linked to the
severity of the presenting
symptoms ( very urgent, urgent,
less urgent, not urgent).
Poison regression model.
Logistic regression model.
The matching of different
variables shows that:
The socioeconomic status
was the same between
copagrp.and controlgrp. 2
group, but both higher than
crtl.1 grp.
Lesser use of ED in copa-grp
than in controlgrp 1 and
2,but smaller in 2. Residents
of poor neighbourhoods of
all grps had 22 % more visits
to ED.
Decline in visits in 1993 was
15 % greater in the copa-grp
than in either ctrlgrp.(p<
0,001) after adjustment.
The use of urgent care and
office visits were higher in
ctrlgrp 1,especially for
paediatric visits.
For visits involving less
severe diagnoses the
declines were greater in the
copagrp. Than in the ctrlgrp.
The always a emergency
visits remains stable in the 3
grps.
The amount of co-payment
had no effect on the change
of use.
Hospital admissions
- A co-payment of 25-35
usd for use of ED led to a
15% reduction with no
increase in use of
outpa.services.
- Copa reduces ED use
more for often not an
emergency". Like in
OÊGrady study the
reduction reduced
especially the lesser
appropriate visits.
- The day(triage) and
night(no triage)
differential for the
reduction of visits dealing
with often not an
emergency was larger at
night. This shows
indirectly that a triage has
an effect.
- Other studies( Lohr et
al..1986) shows that large
co-payments reduce
appropriate preventive
services and screening
mammography. This study
could not show an
adverse effect.
- A greater impact on
lower-income socialgrps
has been demonstrated in
the use of ED at a base
line.