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Gender Differences in the Utilization of Emergency Department Services a
b
Ofra Anson PhD , Sara Carmel PhD & Mordechai Levin MD a
Department of Sociology of Health, Ben-Gurion University of the Negev, Beer-Sheva, 84105, Israel b
Department of Sociology of Health, Ben Gurion University of the Negev, Beer-Sheva, 84105, Israel c
Emergency Department, Faculty for Health Sciences, BenGurion University of Negev, Beer-Sheva, 84105, Israel Published online: 05 Nov 2010.
To cite this article: Ofra Anson PhD , Sara Carmel PhD & Mordechai Levin MD (1991) Gender Differences in the Utilization of Emergency Department Services, Women & Health, 17:2, 91-104, DOI: 10.1300/J013v17n02_05 To link to this article: http://dx.doi.org/10.1300/J013v17n02_05
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages,
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Downloaded by [New York University] at 05:47 08 February 2015
Gender Differences in the Utilization of Emergency Department Services Ofra Anson, P h D Sara Carmel, P h D Mordechai Levin, MD
ABSTRACT. Some of the suggested explanations of the well documented gender morbidity differences imply that these are not 'real' but the result of women's tendency to perceive and report more symptoms, to magnify symptom severity, and to seek help. To contribute to this debate, gender differences in utilization of a general hospital emergency department (ED), often used as a primary care service and for mild conditions, were studied. Data were collected from the general ED admissions registry for 6815 patients. In our data strikingly more men than women visited the ED during the period studied; generally, the same proportion of men and women were self-referred patients; and similar rates of both sexes were hospitalized regardless of type of referral. Thus, these findings suggest that, at least among ED patients, there is no gender differential in symptoms perception, evaluation, or presentation. Indications for these were somewhat found among young patients (aged 17-24) only. Alternatively, the findings with regard to this age group could reflect professional gender stereotyping at the primary care level.
INTRODUCTION It has been consistently shown that men and women differ in health status and illness behavior (Nathanson, 1975, 1977; Verbrugge, 1976a, 1976b, 1982,1985, 1986). After the age of 17, Ofra Anson and Sara Carmel are affiliated with the Department of Sociology of Health and Mordechai Levin is affiliated with the Emergency Department, Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, 84105, Israel. Women & Health, Vol. 17(2) 1991 The Haworth Press, Inc. All rights reserved.
O 1991 by
91
Downloaded by [New York University] at 05:47 08 February 2015
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WOMEN & HEALTH
morbidity rates of women are higher than those of men, with women presenting more acute conditions (except for injuries), and more chronic diseases (except for fatal chronic conditions). The surplus morbidity of women persists even when reproductive-related conditions are excluded (Verbrugge, 1985, 1986). The excess involvement of women in illness behavior is reflected in more frequent sick-role behavior, greater medication usage, and higher rates of utilization of health services such as physicians' offices, out-patient clinics, and hospitals (Kasper, 1982; Meninger, 1986; Rossiter, 1983; Central Bureau of Statistics and Ministry of Health, 1980, 1983). To the best of our knowledge, no research has yet concentrated on gender differences in the utilization of emergency services. The efforts to explain gender health differences have led social scientists to look at gender roles and socially attributed personality traits (Anson et al., 1990; Mechanic, 1976; Nathanson, 1975, 1977; Verbrugge, 1985). It has been argued that women are socialized to, and indeed do, perceive more symptoms than men, and that once symptoms are detected, women tend to evaluate them more severely than men (Hibbard and Pope, 1983). Further, it has been suggested that women's social roles and traits, such as the expectation of women to be weaker than men and in need of help, enable them to assume the sick role and to seek medical assistance more easily than men (Gove, 1984; Gove and Hughes, 1979; Marcus and Seeman, 1981; Marcus and Siegel, 1982; Marcus et al., 1983, 1985; Sindelar, 1982; Thompson and Brown, 1980). These explanations have led some to propose that gender health differences are not 'real,' but rather, an artifact of symptom perception, interviewing or help seeking behavior (Radloff, 1975; Weissman and Klerman, 1977; Gove, 1979; Verbrugge, 1985). Yet, as Verbrugge (1985) noted, there is no solid empirical evidence to support this argument. By focusing on gender differences in utilizing emergency department facility (ED) and the consequent hospitalization rates, we hope to make some contribution to the reall artifact debate. Review of the literature regarding ED utilization reveals that much research has been devoted to the understanding of the dramatic increase in the utilization of that facility observed in most
Downloaded by [New York University] at 05:47 08 February 2015
Anson, Cormel, and Levin
93
Western countries (for review see Davidson, 1978; Ullman et al., 1975). Two issues from this body of research are of particular relevance here. First, there is an agreement that EDs are being increasingly used for non-emergency cases. Perkoff and Anderson (1970), for example, in a study of 6688 ED patients' charts, reasoned that only 29.3% of them were emergency cases, i.e., severe enough to be treated by a secondary health care facility. Second, it has been consistently shown that many ED patients use the facility as a primary care service, independently of the structure of the health care system or the availability of primary care services (Levental, 1983). Thus, whether the health care system is socialized, such as the English and the Israeli systems (Levental, 1983; Reilly, 1981; Wilkinson, 1977) or private (such as the USA system [Bohland, 1984]), at least half of ED users have not consulted any primary care provider before their visit to the ED. The suggestions that gender roles and traits convey and enable gender differences in symptom perception, symptom reporting and presentation, and help seeking behavior, combined with the observation that many ED patients are not emergency cases and use the facility as a primary care setting, lead us to expect that:
1. more women than men will use the ED, similar to the patterns reported for other illness behaviors and as a result of the presentation of symptom to primary care providers; 2. more women than men will use the ED as a primary care service, i.e., self-referred patients, who initiate the ED visit. Moreover, if gender health differences are the result of symptom perception and assessment, than it may be predicted that: 3. fewer women than men will be hospitalized following the ED visit; 4. gender differences in hospitalization rates (women being less likely to be hospitalized) will be larger among the self-referred ED patients.
As mentioned, gender differences in patterns of general ED utilization by the adult population have not been studied as such. However, studies in which some data about utilization rates by gender
Downloaded by [New York University] at 05:47 08 February 2015
94
WOMEN & HEALTH
were included present inconsistent findings. In the USA, Glass and Friedman (1977), reporting data from Mount Sinai ED, found the expected pattern, with three women registered for every two men. About the same time, Ullman et al. (1975), who studied an ED at Vermont, reported that men consisted 54% of the ED patients. Similar observations were found in Ireland (Reilly, 1981) and in Israel (Urman and Lamkin, 1973). More recently, Ettinger et al. (1987), who compared elderly ED patients with patients younger than 65, found no gender differences: the femalelmale ratio was 0.9 among the younger patients and 1.1 among the elderly. These findings, however, should be cautiously interpreted, since they are not strictly comparable: EDs vary both by the age of the patients served and by the span of the conditions treated. The ED under study, as described below, specializes in attending adults, and non-reproductive problems.
THE SETTING The ED under study is located in a teaching hospital, the only one in the Negev region, serving some 215,000 Jewish residents (Statistical Abstract of Israel, 1984). About half (110,000) of the Jewish residents in the region live in the chief city of the region, in which the medical center under study is located, another 55,000 in small urban settlements (up to 14,000), and the rest in rural villages. Primary and emergency health services are available for all residents 24 hours a day seven days of the week. In each settlement, neighborhood primary care clinics, run by sick-funds, are available during official working hours, complemented by emergency primary services offered by the ministry of health which are located at urban centers. The general ED serves the adult population while children and women with reproductive-related conditions are treated in two other specialized EDs in the medical center. The clear division of labor between the general and the Obstetrics-Gynecology (OBGYN) EDs provide the opportunity to study gender differences in ED utilization exclusive of reproduction-related conditions. Every woman whose referral letter or presenting symptoms indicate that her condition is reproductive-system related is referred to the OBGYN ED
Downloaded by [New York University] at 05:47 08 February 2015
Anson, Camel, and Levin
95
without being registered in the general ED; any woman whose condition is not related to the reproductive system will be referred from the OBGYN ED back to the general ED. Thus, pregnant women with common complaints, such as low-back pains or urinary infections, are referred from the OBGYN ED to the general ED for treatment, and menopausal women with vaginal bleeding are not registered as general ED patients, but sent to the OBGYN ED. Both EDs' services are available to all the residents in the region, treating patients referred by primary care providers as well as self-referred patients. It should be noted that 95.4% of the Israeli population carry health insurance (sick-funds) which cover hospital expenses (Statistical Abstract of Israel, 1983).
THE DATA Data were collected from the general ED admissions registry. Jewish patients who arrived at the ED during the first week of every even month from September 1986 to August 1987 (N = 6815) were selected for this study (because of the size of the sample, significance level was set at p < .01). The ED admissions registry includes information about the patient's time of arrival, age, sex, place of residence, type of referral, the ED section of treatment (mainly surgical, orthopedic, or internal), cause of referral (car/ work accidents or other), and disposition (hospitalization or discharge). Since health status and gender health differences are strongly related to age, the analysis will consider four age groups: young adults (age 17-24); adults (ages 25-44 and 45-64); and older patients (aged 65 + ).
FINDINGS The most striking finding is that, contradictory to other types of illness behavior, more men than women make use of the ED. Although women compose about 52% of the adult population in the Negev region, and account for 60.4% of the primary care doctor visits in the region (Zemora, 1984), they comprise only two-fifths (39.9%) of the patients in the ED (Table 1). This observed gender
WOMEN % HEALTH T a b l e 1: V i s i t s t o t h e ED b y Age and Gender (percents)
611 P a t i e n t s Age
Men
Women
I I M/W I ratio I
I n j u r i e s Encluded Men
Women
n/w
ratio
Downloaded by [New York University] at 05:47 08 February 2015
I 17-24
65.7 (948)
34.4 (492)
25-44
64.1 (1599)
35.9 1902)
45-64
53.1 (887)
46.9 (781)
L5+
54.5 (657)
45.5 (549)
Total
LO. 1 (N=4091)
39.9 (N=2724)
Chi -square d.f. F'
Women & Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wwah20
Gender Differences in the Utilization of Emergency Department Services a
b
Ofra Anson PhD , Sara Carmel PhD & Mordechai Levin MD a
Department of Sociology of Health, Ben-Gurion University of the Negev, Beer-Sheva, 84105, Israel b
Department of Sociology of Health, Ben Gurion University of the Negev, Beer-Sheva, 84105, Israel c
Emergency Department, Faculty for Health Sciences, BenGurion University of Negev, Beer-Sheva, 84105, Israel Published online: 05 Nov 2010.
To cite this article: Ofra Anson PhD , Sara Carmel PhD & Mordechai Levin MD (1991) Gender Differences in the Utilization of Emergency Department Services, Women & Health, 17:2, 91-104, DOI: 10.1300/J013v17n02_05 To link to this article: http://dx.doi.org/10.1300/J013v17n02_05
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages,
c
and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [New York University] at 05:47 08 February 2015
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
Downloaded by [New York University] at 05:47 08 February 2015
Gender Differences in the Utilization of Emergency Department Services Ofra Anson, P h D Sara Carmel, P h D Mordechai Levin, MD
ABSTRACT. Some of the suggested explanations of the well documented gender morbidity differences imply that these are not 'real' but the result of women's tendency to perceive and report more symptoms, to magnify symptom severity, and to seek help. To contribute to this debate, gender differences in utilization of a general hospital emergency department (ED), often used as a primary care service and for mild conditions, were studied. Data were collected from the general ED admissions registry for 6815 patients. In our data strikingly more men than women visited the ED during the period studied; generally, the same proportion of men and women were self-referred patients; and similar rates of both sexes were hospitalized regardless of type of referral. Thus, these findings suggest that, at least among ED patients, there is no gender differential in symptoms perception, evaluation, or presentation. Indications for these were somewhat found among young patients (aged 17-24) only. Alternatively, the findings with regard to this age group could reflect professional gender stereotyping at the primary care level.
INTRODUCTION It has been consistently shown that men and women differ in health status and illness behavior (Nathanson, 1975, 1977; Verbrugge, 1976a, 1976b, 1982,1985, 1986). After the age of 17, Ofra Anson and Sara Carmel are affiliated with the Department of Sociology of Health and Mordechai Levin is affiliated with the Emergency Department, Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, 84105, Israel. Women & Health, Vol. 17(2) 1991 The Haworth Press, Inc. All rights reserved.
O 1991 by
91
Downloaded by [New York University] at 05:47 08 February 2015
92
WOMEN & HEALTH
morbidity rates of women are higher than those of men, with women presenting more acute conditions (except for injuries), and more chronic diseases (except for fatal chronic conditions). The surplus morbidity of women persists even when reproductive-related conditions are excluded (Verbrugge, 1985, 1986). The excess involvement of women in illness behavior is reflected in more frequent sick-role behavior, greater medication usage, and higher rates of utilization of health services such as physicians' offices, out-patient clinics, and hospitals (Kasper, 1982; Meninger, 1986; Rossiter, 1983; Central Bureau of Statistics and Ministry of Health, 1980, 1983). To the best of our knowledge, no research has yet concentrated on gender differences in the utilization of emergency services. The efforts to explain gender health differences have led social scientists to look at gender roles and socially attributed personality traits (Anson et al., 1990; Mechanic, 1976; Nathanson, 1975, 1977; Verbrugge, 1985). It has been argued that women are socialized to, and indeed do, perceive more symptoms than men, and that once symptoms are detected, women tend to evaluate them more severely than men (Hibbard and Pope, 1983). Further, it has been suggested that women's social roles and traits, such as the expectation of women to be weaker than men and in need of help, enable them to assume the sick role and to seek medical assistance more easily than men (Gove, 1984; Gove and Hughes, 1979; Marcus and Seeman, 1981; Marcus and Siegel, 1982; Marcus et al., 1983, 1985; Sindelar, 1982; Thompson and Brown, 1980). These explanations have led some to propose that gender health differences are not 'real,' but rather, an artifact of symptom perception, interviewing or help seeking behavior (Radloff, 1975; Weissman and Klerman, 1977; Gove, 1979; Verbrugge, 1985). Yet, as Verbrugge (1985) noted, there is no solid empirical evidence to support this argument. By focusing on gender differences in utilizing emergency department facility (ED) and the consequent hospitalization rates, we hope to make some contribution to the reall artifact debate. Review of the literature regarding ED utilization reveals that much research has been devoted to the understanding of the dramatic increase in the utilization of that facility observed in most
Downloaded by [New York University] at 05:47 08 February 2015
Anson, Cormel, and Levin
93
Western countries (for review see Davidson, 1978; Ullman et al., 1975). Two issues from this body of research are of particular relevance here. First, there is an agreement that EDs are being increasingly used for non-emergency cases. Perkoff and Anderson (1970), for example, in a study of 6688 ED patients' charts, reasoned that only 29.3% of them were emergency cases, i.e., severe enough to be treated by a secondary health care facility. Second, it has been consistently shown that many ED patients use the facility as a primary care service, independently of the structure of the health care system or the availability of primary care services (Levental, 1983). Thus, whether the health care system is socialized, such as the English and the Israeli systems (Levental, 1983; Reilly, 1981; Wilkinson, 1977) or private (such as the USA system [Bohland, 1984]), at least half of ED users have not consulted any primary care provider before their visit to the ED. The suggestions that gender roles and traits convey and enable gender differences in symptom perception, symptom reporting and presentation, and help seeking behavior, combined with the observation that many ED patients are not emergency cases and use the facility as a primary care setting, lead us to expect that:
1. more women than men will use the ED, similar to the patterns reported for other illness behaviors and as a result of the presentation of symptom to primary care providers; 2. more women than men will use the ED as a primary care service, i.e., self-referred patients, who initiate the ED visit. Moreover, if gender health differences are the result of symptom perception and assessment, than it may be predicted that: 3. fewer women than men will be hospitalized following the ED visit; 4. gender differences in hospitalization rates (women being less likely to be hospitalized) will be larger among the self-referred ED patients.
As mentioned, gender differences in patterns of general ED utilization by the adult population have not been studied as such. However, studies in which some data about utilization rates by gender
Downloaded by [New York University] at 05:47 08 February 2015
94
WOMEN & HEALTH
were included present inconsistent findings. In the USA, Glass and Friedman (1977), reporting data from Mount Sinai ED, found the expected pattern, with three women registered for every two men. About the same time, Ullman et al. (1975), who studied an ED at Vermont, reported that men consisted 54% of the ED patients. Similar observations were found in Ireland (Reilly, 1981) and in Israel (Urman and Lamkin, 1973). More recently, Ettinger et al. (1987), who compared elderly ED patients with patients younger than 65, found no gender differences: the femalelmale ratio was 0.9 among the younger patients and 1.1 among the elderly. These findings, however, should be cautiously interpreted, since they are not strictly comparable: EDs vary both by the age of the patients served and by the span of the conditions treated. The ED under study, as described below, specializes in attending adults, and non-reproductive problems.
THE SETTING The ED under study is located in a teaching hospital, the only one in the Negev region, serving some 215,000 Jewish residents (Statistical Abstract of Israel, 1984). About half (110,000) of the Jewish residents in the region live in the chief city of the region, in which the medical center under study is located, another 55,000 in small urban settlements (up to 14,000), and the rest in rural villages. Primary and emergency health services are available for all residents 24 hours a day seven days of the week. In each settlement, neighborhood primary care clinics, run by sick-funds, are available during official working hours, complemented by emergency primary services offered by the ministry of health which are located at urban centers. The general ED serves the adult population while children and women with reproductive-related conditions are treated in two other specialized EDs in the medical center. The clear division of labor between the general and the Obstetrics-Gynecology (OBGYN) EDs provide the opportunity to study gender differences in ED utilization exclusive of reproduction-related conditions. Every woman whose referral letter or presenting symptoms indicate that her condition is reproductive-system related is referred to the OBGYN ED
Downloaded by [New York University] at 05:47 08 February 2015
Anson, Camel, and Levin
95
without being registered in the general ED; any woman whose condition is not related to the reproductive system will be referred from the OBGYN ED back to the general ED. Thus, pregnant women with common complaints, such as low-back pains or urinary infections, are referred from the OBGYN ED to the general ED for treatment, and menopausal women with vaginal bleeding are not registered as general ED patients, but sent to the OBGYN ED. Both EDs' services are available to all the residents in the region, treating patients referred by primary care providers as well as self-referred patients. It should be noted that 95.4% of the Israeli population carry health insurance (sick-funds) which cover hospital expenses (Statistical Abstract of Israel, 1983).
THE DATA Data were collected from the general ED admissions registry. Jewish patients who arrived at the ED during the first week of every even month from September 1986 to August 1987 (N = 6815) were selected for this study (because of the size of the sample, significance level was set at p < .01). The ED admissions registry includes information about the patient's time of arrival, age, sex, place of residence, type of referral, the ED section of treatment (mainly surgical, orthopedic, or internal), cause of referral (car/ work accidents or other), and disposition (hospitalization or discharge). Since health status and gender health differences are strongly related to age, the analysis will consider four age groups: young adults (age 17-24); adults (ages 25-44 and 45-64); and older patients (aged 65 + ).
FINDINGS The most striking finding is that, contradictory to other types of illness behavior, more men than women make use of the ED. Although women compose about 52% of the adult population in the Negev region, and account for 60.4% of the primary care doctor visits in the region (Zemora, 1984), they comprise only two-fifths (39.9%) of the patients in the ED (Table 1). This observed gender
WOMEN % HEALTH T a b l e 1: V i s i t s t o t h e ED b y Age and Gender (percents)
611 P a t i e n t s Age
Men
Women
I I M/W I ratio I
I n j u r i e s Encluded Men
Women
n/w
ratio
Downloaded by [New York University] at 05:47 08 February 2015
I 17-24
65.7 (948)
34.4 (492)
25-44
64.1 (1599)
35.9 1902)
45-64
53.1 (887)
46.9 (781)
L5+
54.5 (657)
45.5 (549)
Total
LO. 1 (N=4091)
39.9 (N=2724)
Chi -square d.f. F'
