Journal Reviews

Hsu J, Reed M, Brand R, et al. Cost sharing: Patient knowledge and effects on seeking emergency department care. Med Care 2004; 42:290-296.

These researchers from the Kaiser Foundation Research Institute in Oakland, CA, and other institutions studied how patients’ knowledge of health care expenses affected their use of emergency services in the community.

The use of cost sharing to control health care expenditures is increasing, they noted, but there is little information about patients’ knowledge of cost sharing or its influence on behavior.

They conducted a cross-sectional telephone survey of a stratified random sample of 695 adult patients in an integrated delivery system, with a 69% response rate.

The survey included perceived and actual levels of copayments for ED visits, office visits, and prescription drugs; and self-reports of copayment-related behavior changes.

One third of the subjects correctly reported their ED copayment, and three fourths correctly reported their prescription drug and office visit copayments. More than half of the subjects (57%) underestimated their ED copayment by $20 or more.

Among patients who reported having any copayment, 11% described changing their behavior because of the copayment, for instance by delaying or avoiding emergency care.

The researchers noted, "The perceived copayment level was strongly associated with behavior change. Other significant factors included having more ED visits in the past 12 months and having a low health status."

Patients have less knowledge of their ED cost-sharing levels than for other health care services, the researchers concluded.

The perceived copayment amount was strongly associated with avoidance of or delays in emergency care, but they said further research is necessary to determine whether that effect is positive or negative.


Saketkhoo DD, Bhargavan M, Sunshine JH, et al. Emergency department image interpretation services at private community hospitals. Radiology 2004; 231:190-197.

Radiologic image interpretation varies greatly among EDs; in fact, it varies so much that patient care may be affected, cautioned these researchers from Yale University in New Haven, CT.

The authors contacted a random national sample of 114 hospitals by telephone and administered a questionnaire that included queries about daytime image interpretation duties, nighttime radiology coverage arrangements, and radiologist staffing needs. They stratified on the basis of ED patient volumes and trauma center designation.

Results were obtained from 97 EDs. Community hospital radiologists performed daytime primary interpretation of radiographs at 39 (40%) of 97 EDs, computed tomographic (CT) scans at 91 (95%) of 96 EDs, and ultrasonographic images at 87.5 (93%) of 94 EDs. Only two EDs (2%) had "ED-dedicated" radiologists performing emergency radiology work.

At night, eight (8%) of 97 EDs had no radiology coverage, 80 (82%) of 97 EDs used teleradiology services in some form, and nine (9%) of 97 EDs employed in-house, rotating "non-ED-dedicated" radiologists.

Clinicians at 37 (38%) of 97 EDs were able to consult radiologists for nighttime radiography questions, and 87 (92%) of 95 EDs had nighttime CT scans read by radiologists in time for patient care decisions.

Twenty-four (25%) of 97 EDs reported radiologist staffing shortages, but only one indicated that it was actively trying to recruit ED-dedicated radiologists.

Higher ED patient volumes and the presence of a trauma center each significantly increased the probability of higher nighttime levels of radiologist coverage.

The researchers conclude that there is "great variation" in emergency radiology services in private community hospitals and that more uniform radiology coverage may improve patient care.


Lyons MS, Lindsell CJ, Trott AT. Emergency department pelvic examination and Pap testing: Addressing patient misperceptions. Acad Emerg Med 2004; 11:405-408.

Many women treated in the ED mistakenly assume they have received Papanicolaou (Pap) smear testing, according to this research from the University of Cincinnati College of Medicine.

The researchers theorized that some women fail to obtain cervical screening because they do not adequately understand the need or the test itself, so they studied the understanding among women undergoing ED pelvic examination and the feasibility of educating patients in the ED.

The study involved patients undergoing pelvic examination in an urban, tertiary care ED. Patients were surveyed about Pap smear screening, and among the initial cohort, no education was provided prior to survey administration. Then they implemented a pilot study of scripted information provided by physicians alone or physicians and counselors.

There were 81 patients in the nonintervention cohort and 32 patients in the intervention cohort. Of the 32 intervention patients, 16 received physician-administered intervention, and 16 received reinforced counseling (physician and counselor). Of 113 total patients, 90 (82%) were African-American, and the mean age was 26 years.

Of the 81 nonintervention patients, six (7%) said they were told that a Pap test was not done, and 60 (74%) mistakenly believed they had a Pap test.

Sixty-six (81.5%) patients stated they knew the purpose of a Pap test, but only 17 (26%) of these patients correctly identified the Pap test as a test for cervical cancer.

All 32 intervention patients were surveyed after physician counseling. Compared with the nonintervention group, fewer (56%) thought they had a Pap test, and more (31%) said they were told they did not receive a Pap test.

All 16 reinforced intervention patients correctly denied receiving a Pap test after counselor education.

The researchers conclude that "knowledge of Pap testing among women undergoing ED pelvic examination is poor; most mistakenly believe they receive a Pap test during ED evaluation. Educating patients may be feasible and effective in the ED setting."