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FQHC = Federally Qualified Health Center
ED = Emergency Department
“Federally Qualified Health Center Access and Emergency Department Use Among Children” in the October 2016 issue of Pediatrics addresses a timely issue (1). As noted by the authors, studies in this area are needed because it lacks research in children and across multiple health centers.
However, as a pediatrician who has worked in a FQHC, I disagree with the conclusion that the lack of association between penetrance of FQHC services and lower rates of ED use should lead to questioning whether expanding access to care through FQHCs leads to decreased unnecessary use of EDs. Other studies have shown that FQHCs can decrease ED use (2) and an unsubstantiated conclusion could jeopardize FQHC funding. I am writing to note variables in this article that can be enhanced and further explored.
First, this study’s measure of penetrance could be improved to reflect whether patients are using a FQHC as their medical home instead of basing penetrance on having one encounter. Patients who consider a FQHC as their medical home should be less likely to overuse the ED when compared to patients that use a FQHC as a one-time walk-in clinic. In future studies, patients who have established the FQHC as their medical home could be extrapolated by considering who has been seen at a FQHC for a well child check or for multiple visits of any type.
Second, I question the inclusion...
Second, I question the inclusion of all FQHCs in the FQHC density calculation. I appreciate what the authors said regarding FQHC locations with dental and mental health services contributing to medical care that can decrease ED visits. But, if FQHC locations that only serve adults were included in the FQHC density calculation, this would lead to an inaccurate representation of access to care for pediatric patients.
Finally, all ED visits were counted based on the assumption that most pediatric ED visits are non-emergent. Only counting unnecessary ED visits would give a more accurate representation of overutilization of the ED.
I agree with the authors that there are various factors that affect how much a community uses FQHCs which further negates the idea that the results of this study alone should be used to question whether FQHCs can decrease ED use. As mentioned by the authors, one of the factors that can be considered is access to after-hours care. Offering extended hours has been shown to decrease ED utilization (3,4,5). In my clinical experience at a FQHC, making primary care services more accessible by offering extended hours significantly increases patient utilization. When our FQHC no longer offered extended hours for pediatric patients, parents of my patients said they went to the ED for things they knew could be addressed in the clinic.
FQHC access and ED use will continue to be an important topic in delivering healthcare to the underserved. More research is needed to support FQHC funding that enables delivery of healthcare to one of the more vulnerable populations of children.
Latasha Bogues, MD, FAAP
Assistant Professor and General Pediatrician
Morehouse School of Medicine
720 Westview Dr SW, Atlanta, GA 30310
1. Nath JB, Costigan S, Lin F, Vittinghoff E, Hsia RY. Federally Qualified Health Center Access and Emergency Department Use Among Children. Pediatrics. 2016;138(4).
2. Rust G, Baltrus P, Ye J, et al. Presence of a community health center and uninsured emergency department visit rates in rural counties. J Rural Health. 2009;25(1):8–16.
3. Bruni ML, Mammi I, Ugolini C. Does the extension of primary care practice opening hours reduce the use of emergency services? J Health Econ. 2016; 50:144-155.
4. Whittaker W,Anselmi L,Kristensen SR, Lau Y-S, Bailey S, Bower P, et al. Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis. PLoSMed. 2016;13(9):e1002113
5. van Uden CJT, Crebolder HFJM. Does setting up out of hours primary care cooperatives outside a hospital reduce demand for emergency care? Emerg Med J. 2004; 21:722-723.
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