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10 Urgences KCE reports vol. 19B
residential address to their census-block group. The authors found a 14.6% (95% CI : -
23,3 to -5,4) decline in the number of emergency department visits following institution
of a co-payment, mostly among patients Âlikely not to present an emergencyÊ. There was
also a non significant decline in Âalways an emergencyÊ visits. The magnitude of the
decrease in use did not differ according to sex and was not related to age, except for
the steeper decline among children one through five years old. Although not statistically
significant (p=0.13), there was a greater reduction in emergency department use among
residents of poor neighbourhoods (-22.5%) compared to residents of other
neighbourhoods (-14.7%). A limitation of the study is the fact that poverty was rare in
the co-payment group, and that jobless people were excluded which may underestimate
the influence of co-payment on the lower socioeconomic class with regard to
emergency department use. No excess adverse events, examined by the number of
hospitalizations or deaths, were observed in the co-payment group; however the study
had limited ability to detect any adverse effects of the co-payment.
In a retrospective multicenter study, Magid et al. 14 investigated in a single health
maintenance system the association between insurance co-payments and delays in
seeking emergency care among patients with myocardial infarction. There were 602
patients whose health insurance required a co-payment for emergency department care
(range, $25 to $100) and 729 patients with no co-payment requirement. The median
length of time from the onset of symptoms to arrival at the hospital, as adjusted for age,
sex, and race, was 135 minutes for the co-payment group and 137 minutes for the
group with no co-payment (95 percent confidence interval for the difference, -19 to
+16 minutes). There was no significant association between the presence or absence of
a co-payment requirement and the time to arrival at the hospital after adjustment for
calendar year, income, educational level, cardiac history, or clinical symptoms. Since
some patients may be unaware of their co-payment requirement, the authors
performed a subgroup analysis of data on patients who had a previous visit to the
emergency department with the same co-payment status - that is, of patients who were
likely to know about their co-payment. This analysis also showed no significant
association between the requirement for a co-payment and delays in seeking treatment.
The authors conclude that for privately insured patients in this health maintenance
organization, the requirement of modest, fixed co-payments for emergency services did
not lead to delays in seeking treatment for myocardial infarction. A limitation of this
study is the fact that the population was not made up of all patients who presented with
symptoms of possible myocardial infarction, and that patients with myocardial infarction
who stay at home were not included. Furthermore care should be taken in interpreting
these results as no comparison was made with other insurance types, and only very few
indigent people were included in the study.
Following on this study Ho et al. 15 investigated in a retrospective cohort study the
association between Medicare supplemental insurance and delay in seeking emergency
care for patients with myocardial infarction. A comparison was made between the time
from symptom onset to hospital arrival (the time-delay interval) in Medicare patients
with and without supplemental insurance coverage who presented with an acute
myocardial infarction. There were 1373 patients with Medicare-only coverage and 2050
patients with Medicare plus supplemental insurance coverage. The age-, sex-, and raceadjusted
median time delay was 135 minutes for the Medicare-only group and 130
minutes for the Medicare plus supplemental insurance group (P =0.34; 95% confidence
interval for median time-delay difference in minutes -5 to 10). There was no significant
association between the presence of Medicare supplemental insurance coverage and
time delay in Cox regression models, which also adjusted for event year, income,
education, past cardiac history, and clinical symptoms. The authors conclude that for
this cohort of Medicare patients, the absence of supplemental insurance coverage did
not lead to significantly increased delays in seeking care for myocardial infarction. Lack
of supplemental insurance for Medicare patients might not have as great an effect on the
use of emergency services as it has on other health care services.
Europe
La seule étude trouvée en Europe spécifiquement pour évaluer lÊintroduction dÊun
système de co-paiement sur la fréquentation dÊun service dÊurgence est celle de Murphy