Racial and economic composition of emergency department visitors and privacy values: Are first-time visitors different from repeat visitors?

Abstract

Study objectives: Studies of patient satisfaction after an emergency department (ED) visit often focus on methods of improving willingness to return for further care or postvisit satisfaction measures. However, up to half of ED visits are by first-time visitors, and such measures are not applicable to their initial appearance in the ED. Thus, interventions targeted toward improved satisfaction may not be relevant in addressing the preferences of a large segment of the ED population. This study is undertaken to determine the factors first-time visitors value most when choosing an ED, compared with repeat visitors. In addition, demographic factors affecting ED utilization between these groups were assessed. Methods: An observational, prospective survey at an urban Level I trauma center (annual census 64,000) was undertaken. A convenience sample of 346 patients visiting the ED during July and August 2003 was surveyed. Demographics on age, sex, race, insurance status, primary care access, and income were collected. Before their ED encounter, patients quantified the importance of the following aspects of their care a priori from 1 (not important) to 5 (very important): privacy, attentive nurse, diagnosis, informed of delays, wait time, pain relief, trust in providers, and having concerns addressed. These categories have previously been linked to patient satisfaction. A subset of first-time visitors was contacted several weeks after their initial visit to reevaluate their scores on these criteria. First-time visitors and repeat visitors were compared by Wilcoxon rank-sum test, with statistical significance criteria adjusted for multiple tests. Results: First-time visitors comprised 46% of total visits. Between first-time visitors and repeat visitors, median age was 37 years, 56% were women, 84% were insured, and 77% had a primary care physician. Repeat visitors averaged 2.7 visits per year (95% confidence interval [CI] 1.5 to 3.82) and reported lower median annual income than first-time visitors ($34,000 versus $60,000, P =.002). A greater proportion of repeat visitors were black (23% versus 13%, P =.02) and Hispanic (26% versus 13%, P =.007). Both groups valued "trust in providers" most (mean 4.5, 95% CI 4.4 to 4.7). First-time visitors valued privacy less than repeat visitors (3.8 versus 4.3, P =.0001) but were otherwise similar in their preferences. At follow-up, values of first-time visitors were no longer different from those of repeat visitors. Conclusion: Despite similarities in age, sex, and markers for access to care (insurance and a primary care physician), there are significant differences in the racial and economic backgrounds of repeat visitors compared with first-time visitors, which suggests that other factors contribute to increased utilization in this population. Although first-time visitors initially value privacy less than repeat visitors, this changed after experiencing a complete ED visit, which may reflect an initial naivete on the part of first-time visitors about what to expect during a typical ED stay. We conclude that commonly used categories to score patient satisfaction may be used in first-time visitor and repeat visitor populations.