Open Access Research article

Use of the emergency department for less-urgent care among type 2 diabetics under a disease management program

Shang-Jyh Chiou1*, Claudia Campbell2, Ronald Horswell4, Leann Myers3 and Richard Culbertson2

Author Affiliations

1 Department of Health Care Administration, College of Health Science, Asia University, 500, Lioufeng Road, Wufeng, Taichung County 41354, Taiwan

2 Department of Health Systems Management, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 1900, New Orleans, LA 70112, USA

3 Department of Biostatistics, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2000, New Orleans, LA 70112, USA

4 Louisiana State University Health Sciences Center, Health Care Services Division, P.O. Box 91308, Baton Rouge, LA 70821, USA

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BMC Health Services Research 2009, 9:223  doi:10.1186/1472-6963-9-223

Published: 7 December 2009



This study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD).


All ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables.


Patients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect.


Patients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care.