Patient out-of-pocket payments and use of emergency care

Emergency department overcrowding has led to attempts to reduce non-urgent visits and improve patients flows. An increase of the fee patients pay for emergency care is one of the interventions used.

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Published: Report no: ut202413 Registration no: SBU 2024/221

Question

What scientific studies have been published regarding on the effect of patient out-of-pocket payments on emergency care use?

Method

A systematic literature search was performed in MedLine (Ovid) and Scopus.
Two authors independently assessed the abstracts of all identified studies.
Risk of bias in relevant systematic reviews was assessed using an assessment tool based on AMSTAR.

Identified literature

Two systematic reviews relevant to the research question but not transferable to a Swedish setting due to differences in health care systems, and with high risk of bias were identified [1, 2]. No results are reported.

References

  1. Flores-Mateo G, Violan-Fors C, Carrillo-Santisteve P, Peiro S, Argimon JM. Effectiveness of organizational interventions to reduce emergency department utilization: a systematic review. PLoS ONE. 2012;7(5):e35903. Available from: https://doi.org/10.1371/journal.pone.0035903.
  2. Morgan SR, Chang AM, Alqatari M, Pines JM. Non-emergency department interventions to reduce ED utilization: a systematic review. Acad Emerg Med. 2013;20(10):969-85. Available from: https://doi.org/10.1111/acem.12219.

 

Search strategies

Medline via OvidSP 14 May 2024

/ = Term from the MeSH controlled vocabulary; .sh = Term from the MeSH controlled vocabulary; exp = Term from MeSH including terms found below this term in the MeSH hierarchy; .ti,ab = Title or abstract; .tw = Title or abstract; .kf = Keywords; .kw = Keywords, exact; .bt = Book title. NLM Bookshelf; .pt = Publication type; .ja = Journal abbreviation; .af = All fields; adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other; * or $ = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Population:
1. Exp Emergency Medical Services/ 174 123
2. Exp Emergency Service, Hospital/ 102 656
3. Exp Emergency Medicine/ 15 901
4. ((emergency or trauma) adj3 (room* or department* or service* or ward* or unit* or center* or centre* or care)).ab,bt,kf,ti. 229 987
5. or/1-4 315 935
Intervention:
6. Fees, Medical/ 5523
7. “Fees and Charges”/ 9222
8. Hospital Charges/ 3288
9. Cost Sharing/ 2785
10. Health Expenditures/ 24 707
11. (fee or fees).ab,bt,kf,ti. 22 685
12. out of pocket.ab,bt,kf,ti. 8850
13. payment*.ab,bt,kf,ti. 35 755
14. (copay* or ‘co pay*’).ab,bt,kf,ti. 2938
15. ‘cost shar*’.ab,bt,kf,ti. 2446
16. ‘user cost*’.ab,bt,kf,ti. 62
17. charges.ab,bt,kf,ti. 41 342
18. or/6-17 133 295
Outcome:
19. Health Services Accessibility/ 87 134
20. Health Services Misuse/ 4450
21. Health Equity/ 4282
22. Health Behavior/ 57 515
23. (non urgent or nonurgent or non emergency or non emergent or nonemergent or low acuity).ab,bt,kf,ti. 6113
24. (crowding or overcrowding or crowd out).ab,bt,kf,ti. 17 342
25. ((dela* or avoid*) adj3 care).ab,bt,kf,ti. 9169
26. low income.ab,bt,kf,ti. 50 897
27. (utiliz* or overutiliz*) .ab,bt,kf,ti. 857 816
28. ((over or frequent or inappropriate) adj2 use*).ab,bt,kf,ti. 38 608
29. (unnecessary or misuse).ab,bt,kf,ti. 93 953
30. or/19-29 1 192 519
Study types: systematic reviews and meta-analysis
31. ((Systematic Review/ or Meta-Analysis/ or Cochrane Database Syst Rev.ja. or ((systematic adj4 review) or "meta analys*" or metaanalys*).ti,bt,ab.) not (editorial/ or letter/ or case reports/))  
Combined sets:
32. 5 and 18 and 31 58
33. 5 and 30 and 31 974
34. 32 or 33 1003
Final result
35.   1003

Scopus via scopus.com 14 May 2024

TITLE-ABS-KEY = Title, abstract or keywords (including indexed keywords and author keywords); ALL = All fields; W/n = Within. Proximity operator retrieving terms within n words from each other; PRE/n = Precedes by. Proximity operator, the first term in the search must precede the second by n words; LIMIT-TO (X) = Includes only results of specified type, e.g., publication type or time range; DOCTYPE = Publication type; “re” = review; “le” = letter; “ed” = editorial; “ch” = book chapter; “cp” = conference proceedings; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Setting:
1. TITLE-ABS-KEY ( ( emergency OR trauma ) W/2 ( room* OR department* OR service* OR ward* OR unit* OR center* OR centre* OR care ) ) 421 636
Intervention:
2. TITLE-ABS-KEY ( fee OR fees OR "out of pocket" OR payment* OR copay* OR "co pay*" OR "cost shar*" OR "user cost*" OR charges OR “health expenditure*” OR (financial W/2 (incentive* OR barrier*))) 1 458 692
Outcome:
3. TITLE-ABS-KEY ( nonurgent OR "non urgent" OR nonemergent OR "non emergent" OR "non emergency" OR "low acuity" OR crowding OR overcrowding OR "crowd out" OR "low income" OR utiliz* OR overutiliz* OR unnecessary OR misuse ) 3 822 423
4. TITLE-ABS-KEY ( ( dela* OR avoid* ) W/2 care ) 10 943
5. TITLE-ABS-KEY ( ( frequent OR inappropriate ) W/2 use ) 912 208
6. TITLE-ABS-KEY ( "health service* accessibility" OR "health equity" ) 97 834
7. 3 OR 4 OR 5 OR 6 4 763 249
Study types: systematic reviews and meta-analysis
8. TITLE-ABS-KEY ( ( systematic  W/2  review )  OR  "meta analy*"  OR  metaanaly* ) AND (EXCLUDE (DOCTYPE, “le”) OR EXCLUDE (DOCTYPE, “ed”) OR EXCLUDE (DOCTYPE, “ch”) OR EXCLUDE (DOCTYPE, “cp”))    
Combined sets:
9. 1 AND 2 AND 8 141
10. 1 AND 7 AND 8 2062
11. 9 OR 10 2125
Final result
12.   2125

 

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