Emergency Department Utilization in the

United States and Ontario, Canada

Guohua Li, MD, DrPH, Jonathan T. Lau, BA, Melissa L. McCarthy, ScD, Michael J. Schull, MD, MS,
Marian Vermeulen, MHS, Gabor D. Kelen, MD

Abstract
Objectives: The current crisis in the emergency care system is characterized by worsening emergency de-
partment (ED) overcrowding. Lack of health insurance is widely perceived to be a major contributing factor
to ED overcrowding in the United States. This study aimed to compare ED visit rates in the United States
and Ontario, Canada, according to demographic and clinical characteristics.
Methods: This was a cross sectional study consisting of a nationally representative sample of 40,253 ED
visits included in the 2003 National Hospital Ambulatory Medical Care Survey in the United States, and
all ED visits recorded during 2003 by the National Ambulatory Care Reporting System in Ontario, Canada.
The main outcome was the number of ED visits per 100 population per year.
Results: The annual ED visit rate in the United States was 39.9 visits (95% confidence interval = 37.2 to 42.6)
per 100 population, virtually identical to the rate in Ontario, Canada (39.7 visits per 100 population). In both
the United States and Ontario, Canada, those aged 75 years and older had the highest ED visit rate and
women had a slightly higher ED visit rate than men. The most common discharge diagnosis was injury/
poisoning, accounting for 25.6% of all ED visits in the United States and 24.7% in Ontario, Canada. Over-
all, 13.9% of ED patients in the United States were admitted to hospitals, compared with 10.5% in
Ontario, Canada.
Conclusions: ED visit rates and patterns are similar in the United States and Ontario, Canada. Differences
in health insurance coverage may not have a substantial impact on the overall utilization of emergency care.
ACADEMIC EMERGENCY MEDICINE 2007; 14:582–584 ª 2007 by the Society for Academic Emergency
Medicine
Keywords: access to care, emergency care, emergency department crowding, health insurance,
health policy

E
mergency department (ED) overcrowding is the
most important issue facing the emergency care
system today in the United States.1 Patients pre-
senting to the ED wait, on average, 47 minutes before
seeing a physician, and 3.2 hours before being dis-
charged.2 Overcrowding results directly from the de-
mand for emergency care exceeding the capacity of the
emergency care system. According to the Institute of
Medicine,1 between 1993 and 2003, the annual ED patient
volume in the United States increased by 23.6 million
visits (26%). Although the increase in ED patient volume
From the Department of Emergency Medicine, Johns Hopkins
University School of Medicine (GL, JTL, MLM, GDK), Baltimore,
MD; and Institute for Clinical Evaluative Sciences, University of
Toronto (MJS, MV), Toronto, Ontario, Canada.
Received February 2, 2007; revision received February 23, 2007;
accepted February 23, 2007.
Presented in abstract form at the SAEM annual meeting, San
Francisco, CA, May 2006.
Contact for correspondence and reprints: Guohua Li, MD,
DrPH; e-mail: ghli@jhmi.edu.
can be largely accounted for by population growth and
aging,3 inadequate health insurance coverage is widely
perceived to be a major contributing factor to ED over-
crowding in the United States.4,5 In an article published
in JAMA, Hampton stated that EDs in the United States
are flooded by patients without health insurance.5 Empir-
ical evidence for the relationship between health insur-
ance status and ED utilization, however, has been
inconsistent. Previous studies often were limited to pa-
tients in individual EDs and to special patient groups
(e.g., frequent ED users) using case-control and cohort
designs. It is unclear whether ED utilization is associated
with health insurance coverage at the population level.
This study aimed to compare ED utilization rates in
the United States and Canada. Because health care in
Canada is financed through a national health insurance
program that ensures access to basic medical services
(including ED visits) for all eligible residents, contrasting
ED utilization in the United States and Canada may pro-
vide valuable information for understanding the effect of
universal health insurance coverage on emergency care–
seeking behavior and for developing policy interventions
on ED overcrowding.

ISSN 1069-6563 ª 2007 by the Society for Academic Emergency Medicine

582 PII ISSN 1069-6563583 doi: 10.1197/j.aem.2007.02.030
ACAD EMERG MED  June 2007, Vol. 14, No. 6  www.aemj.org 583

METHODS errors for national estimates were calculated as recom-

mended by the National Center for Health Statistics2 and
Study Design were used to generate the 95% confidence intervals. ED uti-
This was a cross sectional survey design that compared lization was measured by the visit rate per capita per year.
the ED utilization rates in 2003 between the United States
and Ontario, Canada. The study was exempted from in- RESULTS
stitutional review board approval by Johns Hopkins Uni-
versity and received approval by the institutional review During 2003, hospital EDs in the United States received
board of the Sunnybrook Health Sciences Center. an estimated 113.9 million visits, yielding an annual rate
of 39.9 visits per 100 population. During the same period,
Study Protocol hospital EDs in Ontario, Canada, reported a total of 4.9
Data for this study came from the National Hospital million visits, with an annual rate of 39.7 visits per 100
Ambulatory Medical Care Survey (NHAMCS) and the population. In both the United States and Ontario, Can-
National Ambulatory Care Reporting System (NACRS). ada, people aged 75 years and older had the highest ED
The NHAMCS, sponsored by the National Center for visit rate and people aged 45 to 64 years had the lowest
Health Statistics, is a national probability sample survey ED visit rate (Table 1). Women had a slightly higher ED
of ambulatory patient visits. The ED component of the visit rate than men: 41.8% versus 37.9% in the United
2003 NHAMCS contains data for 40,253 ED visits se- States and 40.1% versus 39.4% in Ontario, Canada.
lected from 406 nonfederal, acute care hospitals in the The distribution of primary diagnoses for ED patients
United States, with an overall response rate of 85%. In- was similar between the United States and Ontario, Can-
formation about sampling and data collection proce- ada. The top three diagnostic categories were the same:
dures is described in detail elsewhere.2 injury/poisoning (25.6% of all ED visits in the United
The NACRS is an administrative database developed States and 24.7% in Ontario, Canada), symptoms/signs
by the Canadian Institute for Health Information to col- (18.7% and 19.2%, respectively) and respiratory diseases
lect data on ambulatory care, including ED visits. Unlike (12.3% and 11.0%, respectively).
the NHAMCS, the NACRS includes an abstract for all ED The proportion of ED visits that were triaged as emer-
visits. The database is currently utilized only in the prov- gent was 15.2% (95% confidence interval = 13.0% to
ince of Ontario (Ontario) and is maintained by the Cana- 17.4%) in the United States and 10.3% in Ontario, Can-
dian Institute for Health Information. Patient abstracts ada. Overall, 13.9% (95% confidence interval = 12.9% to
are submitted electronically to the NACRS by all hospi- 14.9%) of ED patients in the United States were admitted
tals in Ontario using standard reporting and quality to hospitals, compared with 10.5% in Ontario, Canada.
control protocols, as mandated by the provincial govern- The average ED length of stay was 3.2 hours in the
ment. Detailed information about the NACRS, including United States and 3.1 hours in Ontario, Canada.
the data elements and reporting procedures, is readily
available.6 This study is based on data for 2003, the DISCUSSION
most recent year for which data were available for both
The results from this study indicate that the level of ED
the United States and Ontario, Canada.
utilization in the United States and Ontario, Canada, is
In this study, an ED is defined as a hospital facility that
virtually identical, with an annual rate of about 40 visits
serves unscheduled patients whose conditions may re-
per 100 population. Moreover, the demographic and clin-
quire immediate care, and is staffed by physicians 24
ical characteristics of ED visits in the United States and
hours a day. An ED may have clinical operations in dif-
Ontario, Canada, are generally compatible, except for
ferent areas of the hospital and may have on-site and
acuity. ED patients in the United States are more likely
off-site units that are open less than 24 hours a day
to have health problems that require immediate medical
(e.g., an urgent care center within an ED). ED utilization
attention than in Ontario, Canada. Reflective of the
refers to patient visits to the ED, including all service
greater acuity, ED patients in the United States have a
areas and units operated by the ED. An ED visit is an en-
higher admission rate than in Ontario, Canada.
counter in the ED between a patient seeking care and a
physician or other care provider working under the phy-
sician’s supervision. Visits made by patients who register Table 1
but leave without being seen by a physician or against Emergency Department Visit Rates by Age in the United States
medical advice are included. The immediacy with which and Ontario, Canada, 2003
a patient should be seen is defined differently in the United States Ontario, Canada
United States and Canada, except for the category of No. of Visits per 100 No. of Visits
‘‘emergent.’’ A visit is determined to be emergent if the Age Visits (in Population Visits (in per 100
triage practitioner deems that the patient should be treat- (yr) thousands) (95% CI) thousands) Population
ed immediately, within 15 minutes, and that any delay of
0–14 24,733 40.8 (35.9, 45.7) 906 39.6
care would likely result in deterioration or endanger the 15–24 17,731 44.2 (40.7, 47.7) 687 41.1
patient’s life. The length of stay in the ED refers to the 25–44 32,906 40.0 (37.1, 42.9) 1,329 35.1
duration between time of arrival and time of discharge. 45–64 20,992 30.8 (28.4, 33.2) 1,072 35.0
65–74 7,153 39.5 (35.8, 43.2) 396 46.6
Data Analysis 75 or 10,389 64.2 (58.5, 68.9) 534 73.1
The NHAMCS sample data were weighted to provide na- older
Total 113,903 39.9 (37.2, 42.6) 4,923 39.7
tional estimates of ED visits in the United States. Standard
584
These findings have important implications for health
care policy. Currently, an estimated 46.6 million Ameri-
cans (16%) do not have health insurance,7 and the unin-
sured are widely perceived to be a major contributing
factor to ED overcrowding because they visit the ED
proportionately more than those privately insured.2 Yet,
evidence is mounting that ED utilization is not signifi-
cantly associated with insurance status. Weber et al.8
found that ED utilization is determined by health status
rather than insurance status. The present study provides
compelling epidemiologic evidence that ED utilization
can be similar in settings with substantially different
health insurance systems. Despite universal coverage,
residents in Ontario, Canada, visit hospital EDs at the
same rate as Americans. National data on ED utilization
for Canada are not available. However, the study results
are likely illustrative of the national profile of ED utiliza-
tion, because Ontario accounts for 36% of the total pop-
ulation in Canada and because ED visit rates in other
areas of Canada are similar to the rate in Ontario.9
As a result of high patient volume and limited emer-
gency care capacity, ED overcrowding represents a
serious problem in both the United States and Canada.
While ED utilization for nonemergent medical conditions
is an indicator of unmet health care needs, the underly-
ing causes of ED overcrowding may differ in the United
States and Canada. According to the 2002–2003 Joint
Canada/U.S. Survey of Health,10 unmet health care needs
in the United States are due mainly to the high cost of
medical services, whereas in Canada, long waiting time
for in-office visits to see primary care physicians and spe-
cialists is the chief culprit.
LIMITATIONS
The findings of this study should be interpreted with
caution. The comparison of ED utilization in the United
States and Ontario, Canada, was performed at the popu-
lation level, and no attempt was made to examine the
relationship between health insurance coverage and
ED utilization using multivariate statistical techniques.
Therefore, the finding of similarly high ED visit rates in
the United States and Ontario, Canada, might be attribut-
able to factors other than health insurance coverage. Dif-
ferences in age and gender compositions between the
two populations, however, are negligible, and adjusting
for age and gender did not change the ED visit rates in
any meaningful way (data not shown). This study is based
on data for 2003, and thus the results represent only a
snapshot. ED visit rates in the United States have been in-
creasing in recent years.2 It is unclear whether ED utiliza-
tion in Canada has been changing over time. Future
studies comparing ED utilization in the United States
and Canada could be enhanced by incorporating tempo-
ral trends into the analysis.
CONCLUSIONS
Emergency medical services are an important compo-
nent of the national health system. The ED serves as a
Li et al.  ED UTILIZATION IN THE UNITED STATES AND ONTARIO
safety net for the general population and a critical portal
of admissions to the hospital for the seriously injured or
ill. Overcrowding in the ED can be detrimental to the
quality of emergency care and patient safety.11 Our study
suggests that increasing health insurance coverage of
Americans might not necessarily result in reduced ED
utilization, especially if other access-to-care problems
persist. To reduce ED overcrowding, it is imperative to
bolster the capacity of the emergency care system by
substantially increasing societal investments in ED infra-
structures and personnel.
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