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Potentially Preventable Use of Emergency Services: The Role of Low Health Literacy

Schumacher, Jessica R. PhD*; Hall, Allyson G. PhD; Davis, Terry C. PhD‡,§; Arnold, Connie L. PhD; Bennett, Robert D. BS; Wolf, Michael S. PhD,MPH; Carden, Donna L. MD

doi: 10.1097/MLR.0b013e3182992c5a
Brief Report

Background: Limited health literacy is a barrier for understanding health information and has been identified as a risk factor for overuse of the emergency department (ED). The association of health literacy with access to primary care services in patients presenting to the ED has not been fully explored.

Objective: To examine the relationship between health literacy, access to primary care, and reasons for ED use among adults presenting for emergency care.

Methods: Structured interviews that included health literacy assessment were performed involving 492 ED patients at one Southern academic medical center. Unadjusted and multivariable logistic regression models assessed the relationship between health literacy and (1) access to a personal physician; (2) doctor office visits; (3) ED visits; (4) hospitalizations; and (5) potentially preventable hospital admissions.

Results: After adjusting for sociodemographic and health status, those with limited health literacy reported fewer doctor office visits [odds ratio (OR)=0.6; 95% confidence interval (CI), 0.4–1.0], greater ED use, (OR=1.6; 95% CI, 1.0–2.4), and had more potentially preventable hospital admissions (OR=1.7; 95% CI, 1.0–2.7) than those with adequate health literacy. After further controlling for insurance and employment status, fewer doctor office visits remained significantly associated with patient health literacy (OR=0.5; 95% CI, 0.3–0.9). Patients with limited health literacy reported a preference for emergency care, as the services were perceived as better.

Conclusions: Among ED patients, limited health literacy was independently associated with fewer doctor office visits and a preference for emergency care. Policies to reduce ED use should consider steps to limit barriers and improve attitudes toward primary care services.

*Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI

Department of Health Services, Research, Management and Policy, College of Public Health, University of Florida, Gainesville, FL

Department of Medicine, Feist-Weiller Cancer Center

§Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA

Department of Emergency Medicine, College of Medicine, Gainesville, FL

Feinberg School of Medicine, Northwestern University, Chicago, IL

Abstracts presented at the 2011 Society for Academic Emergency Medicine Meeting in Boston, MA.

D.L.C., A.G.H., T.C.D., and C.L.A.: conceived and designed the study; J.R.S: responsible for data analysis; J.R.S., D.L.C., A.G.H., T.C.D., and M.S.W.: made substantial contributions to data interpretation; D.L.B.: acquired the data; D.L.C. and J.R.S.: drafted the manuscript; all authors contributed substantially to its revision and approved the final version for submission.

Data management using REDCap was supported by the University of Florida Clinical and Translational Science Institute (CTSI) (1 UL1 RR029890 from NIH).

The authors declare no conflict of interest.

Reprints: Jessica R. Schumacher, PhD, Department of Population Health Sciences, University of Wisconsin-Madison, 800 University Bay Drive, Suite 210, Box 9445, Madison 53711, WI. E-mail:

© 2013 by Lippincott Williams & Wilkins.