Nonprice barriers to ambulatory care after an emergency department visit

Availability of timely follow-up care is essential in emergency medicine. We describe nonprice barriers to care experienced by callers reporting to be emergency department (ED) patients in need of follow-up care.

This was a secondary analysis of data collected during a survey of ambulatory clinics in 9 US cities. Research assistants called a random sample of 603 ambulatory clinics, generated from actual ED referral lists. Callers identified themselves as new patients referred by the local ED. Outcome measures were the percentage of callers experiencing failed appointment attempts for a variety of reasons and inconvenience factors associated with the appointment process: number and amount of time spent on hold, voicemail, repeated calls, and total telephone time.

Only 242 (23%) of 1065 total calls resulted in an appointment within one week, for an ultimate caller success rate of 40% (242/603 pseudopatient scenarios). Independent of insurance status, 43% of 603 initial calls to ED referral numbers were unsuccessful: 27% of initial call failures were due to clinic closures, busy signals, voicemail, or personnel too busy to take the call; 6% wrong numbers; 4% disconnected or extended holds; and 6% out of practice scope. If they reached clinic personnel, 55% of callers were placed on hold; average hold time was 2.43 minutes (median 1.35 minutes). Answering system time averaged 1.17 minutes (median 0.68 minutes; range 0.02 to 13.90 minutes). On average, it required 1.7 calls to reach appointment staff and 8% of clinic contacts required 4 or more attempts. Total telephone time averaged 11.1 minutes for successful appointments.

There are important nonprice barriers to obtaining follow-up appointments for urgent conditions, independent of insurance status.