Access to care: A review of the emergency medicine literature

The authors review the evolution of the emergency medicine literature regar ding emergency department (ED) use and access to care over the past 20 year s. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. In the 1980s, the characteriza tion of "nonurgent ED visits" as "inappropriate" and high ED charges led to the targeting of non-emergency ED care as a potential source of savings. D uring the 1990s the literature reveals multiple attempts to identify "inapp ropriate" ED visits and to develop strategies to triage these visits away f rom the ED. By the late 1990s, demonstration of the risks of denying emerge ncy care and more sophisticated analyses of actual costs led to reconsidera tion of initiatives to limit access to ED care and renewed focus on the cri tical role of the ED as a safety net provider. In recent years, "de facto" denials of emergency care due to long ED waiting times and other adverse co nsequences of ED crowding have begun to dominate the emergency medicine hea lth services literature.