Disability and Emergency Department Visits: A Path Analysis of the Mediating Effects of Unmet Healthcare Needs and Chronic Diseases

Abstract

Previous studies identified disabilities and unmet healthcare needs, especially those related to primary healthcare, as predictors of ED use. This study examined the relationship between disability, unmet healthcare needs, chronic diseases, and ED visits in South Korea. This study was a cross-sectional study using the Korean Health Panel Survey collected in 2018. A path analysis was used. Our research found a significant association between disability and ED visits mediated by unmet healthcare needs and chronic diseases. Disability had a significant direct effect on unmet healthcare needs (β = .04, P ≤ .001) and chronic diseases (β = .10, P ≤ .001). However, there was no mediating effect of unmet healthcare needs between disability and ED visits. While barriers to access to care among people with disabilities are widely acknowledged, this study suggests that interventions or programs to reduce ED visits should consider the unique healthcare needs of people with disabilities.

Keywords

people with disabilities disabled persons emergency care emergency department unmet healthcare needs chronic diseases health services accessibility

What we already know?

• People with disabilities were almost twice as likely to visit EDs, aggravating the burden on emergency healthcare systems in South Korea.

• Most studies focused on the relationship between disabilities and unmet healthcare needs, especially those related to primary healthcare. Adequate access to routine or primary care continuity in the communities reduced ED visits by allowing patients to get necessary healthcare services in time.

• People with disabilities are also more likely to have poor, complex health conditions, such as chronic diseases.

What this article adds?

• This study confirmed that disabilities were directly and indirectly associated with ED visits, mediated by unmet healthcare needs and the number of chronic diseases.

• People with disabilities reported higher unmet healthcare needs, and those with higher unmet healthcare needs, reported more chronic diseases associated with increased ED utilization.

• Interventions or programs aimed at reducing ED visits will not be successful without understanding the unique healthcare needs of people with disabilities.

Introduction

Emergency departments (EDs) are safety nets and gatekeepers for the lives and health of the people.¹ Even with its essential role, EDs face several systematic issues, such as delayed initial response at emergency sites due to a lack of knowledge among the general public and emergency health professionals, limited resources of emergency transportation such as emergency helicopters, and a declining numbers of hospitals operating EDs due to low profitability among hospitals.^1-3 Along with these challenges, substantial numbers of patients using EDs increase yearly while insufficient beds to receive these patients remain—in other words, ED overcrowding.^1,3 This overcrowding aggravates long waiting hours for patients while inadequate emergency healthcare professionals deal with current ED patients.³

While these systematic issues are universal, people with disabilities are nearly twice as likely to visit EDs aggravating the burden on emergency healthcare systems in South Korea.⁴ Previous studies from other countries reported links between disabilities and the likelihood of visiting EDs.^5-8 Disability is defined by the World Health Organization (WHO) as “an umbrella term for impairments, activity limitations, and participation restrictions.” This indicates that people with disabilities have a loss or abnormality in body structure or physiological function and limits on executing activities.⁹ Most studies suggested the factors affecting the frequent ED visits among people with disabilities as limited access to care, specifically, lack of access to primary care.^4,6-8 While people with disabilities used healthcare services more frequently than those without disabilities, it is speculated that healthcare services among people with disabilities were insufficient to prevent visiting EDs.^5,7

Unmet healthcare needs occur when people need healthcare services but have yet to receive them for various reasons.¹⁰ Satisfactory access to usual or primary care continuity in the communities reduced ED visits by allowing patients to get necessary healthcare services in time.^11,12 Unmet healthcare needs were reported higher among people with disabilities than the general population.¹³ The reason for unmet healthcare needs among the general population was primarily due to the limited time to visit hospitals. However, people with disabilities reported that their main reason for unmet healthcare needs was insufficient money for medical costs or limited access to medical institutes.^13,14

People with disabilities are also more likely to have poor and complex health conditions.^7,15 Their perceived health was more unsatisfactory than the general population.¹⁵ In a survey on perceived health among people with disabilities, about half of the respondents (50.2%) reported that their health was “very bad” or “bad,” whereas only 16.2% reported “good.”¹⁵ And, 70.6% of people with disability had one or more chronic diseases.¹⁵ In 2017, the average number of days per year of getting medical services among people with disabilities was 56.5 days, 2.6 times more than those without disabilities (21.6 days per year).¹⁶ Also, the average medical cost per day for people with disabilities was about $70, more than those without disabilities ($48 per day).¹⁶ People with disabilities have more difficulty in managing their health due to their disability itself and socioeconomic factors (eg, job loss, low income, lack of social and governmental support). They are prone to chronic diseases and secondary health conditions such as bowel or bladder problems, injury, fatigue, mental health, depression, and weight problems.^17,18 According to the report by the National Rehabilitation Center in South Korea, the prevalence of hypertension and diabetes among people with disabilities was 44.5% and 20.8%, higher than those of the total population (33.5% and 13.0%).¹⁹

Most studies identified a relationship between disabilities and unmet healthcare needs, especially related to primary healthcare. Furthermore, there is a need to consider whether disabilities are associated with ED visits and how underlying mechanisms, especially in relation to unmet healthcare needs, are interrelated. Understanding how people with disabilities end up visiting EDs would inform healthcare programs and policies to reduce the use of EDs for people with disabilities. The present study extends these previous findings by investigating these relationships using path analysis. This study aimed to examine the relationship between disability, unmet healthcare needs, chronic diseases, and ED visits among nationally representative groups of people with and without disabilities in South Korea. We hypothesized that having disabilities would be positively related to ED visits (H1), which would be mediated by unmet healthcare needs (H2) or chronic diseases (H3). A pathway through unmet healthcare needs and chronic disease may mediate the relationship between disabilities and ED visits (H4) (Figure 1).

Figure 1.

Hypothesized model.

Methods

This cross-sectional study used the Korean Health Panel Survey collected in 2018.

Data Source

This study used the Korean Health Panel Survey (KHPS) data. The survey provides data on healthcare behaviors and expenditures by the Korea Institute for Health and Social Affairs and National Health Insurance Service.²⁰ The data collection for the KHPS started in 2008 and has been conducted annually. Sample households were selected using stratified cluster sampling by districts and a proportionate probability sampling with the stratified samples.²¹ The initial sample size was approximately 8000 households with family members in 2008. Trained personnel visited each household to ask questions using computer-assisted personal interviewing methods.²⁰ The survey contents were broad to capture the factors related to health behavior and expenditures by including socioeconomic characteristics, medical costs (eg, pharmacy, long-term care), employment, income, health status, healthcare utilization (eg, inpatient and outpatient clinics, emergency care, Korean traditional medicine and, dental clinics), source of health insurance, healthy lifestyle, quality of life.²² In this study, we used the survey data collected in 2018 (KHPS version 1.7) from 6379 households with 17 008 family members. Among the data, we extracted respondents who answered the questions related to our study variables (eg, disability, unmet healthcare needs, chronic diseases, etc.) and aged 18 and older. We included 13 083 respondents for the final analysis.

Measurements

Disability

The Act On the Welfare of Persons With Disabilities defines a person with a disability as “a person whose daily life or social activity is substantially hampered by physical or mental disability over a long period.”²³ The types of disability were classified into 15 categories: physical, brain, visual, auditory, speech, developmental (autism), mental, kidney, heart, respiratory, liver, facial, stoma, and epilepsy.²³ Disability was the exogenous variable of interest. The respondents were asked if they have any disabilities diagnosed under the category above and registered with Korea’s Ministry of Health and Welfare. The answer then was dichotomized into having at least one disability or not having any disability.

Unmet healthcare needs and chronic diseases

This study included two mediating variables; unmet healthcare needs (dichotomous variable) and the number of chronic diseases (continuous variable). The respondents were asked if they ever had an occasion of not receiving treatment or examination that they needed (except dental care services) in the past 12 months, whether it be more than once, not at all, or if they did not have any healthcare needs. The answer was then dichotomized into having at least one occasion of unmet healthcare needs and not having any. Respondents were also asked if they had any chronic diseases such as hypertension, diabetes, hyperlipidemia, arthritis, tuberculosis, ischemic heart disease, cerebrovascular disease, dementia, depression, or chronic kidney failure. The respondents could answer any multiple chronic diseases they had. The number of chronic diseases of each respondent was then summed up.

ED visits

The outcome variable was the event of an ED visit. Respondents were asked how often they visited EDs in the past 12 months. The answer was then dichotomized into visiting ED at least once or not visiting the ED at all.

Age and gender

We controlled two variables—age and gender. Age was calculated from the year of birth reported by the respondents. Gender was controlled with a dummy variable indicating female respondents (1 = female).

Data Analysis

Descriptive analyses were conducted using SPSS (Version 20) to identify participants’ characteristics concerning demographics and all study constructs (ie, disability, unmet healthcare needs, ED visits). This study used path analysis to estimate the relationship between the predictor variables of primary interest (disability), mediating variables (unmet healthcare needs and chronic diseases), and ED visits using MPlus Version 8.7. This analysis included two demographics (age and gender) as control variables because of their potential effects on disabilities, chronic diseases, and ER visits. The unit of analysis was the individual respondents. All results are presented as standardized regression coefficients to facilitate comparisons across variables. Mediation analyses using a bootstrapping approach with 10 000 replications were employed to examine the mediation effects. An indirect effect was evident if the path estimate generated confidence intervals (CIs) and did not include zero.²⁴ The sample size was adequate because of the number of variables and the statistical model we used (path analysis rather than structural equation modeling).^25-27 Ethical review and approval were waived for this study by the Samsung Medical Center Institutional Review Board because it was a secondary data analysis of an anonymous sample that did not include any information to identify the survey participants (SMC202005065).

Results

Descriptive Statistics

People with disabilities (16.45%) were more likely to visit ED in the past 12 months than people without disabilities (9.45%). In terms of unmet healthcare needs, people with disabilities (18.06%) were more likely to have not received the healthcare services that they needed in the past 12 months compared to people without disabilities (11.93%, P < .001). People with disabilities had significantly more chronic diseases (M = 3.81, SD = 2.74) than people without disabilities (M = 1.88, SD = 2.24, P < .001). The average age of people with disabilities was significantly older (M = 66.76, SD = 15.31) compared to the average age of people without disabilities (M = 52.91, SD = 17.92, P < .001) (Table 1).

Table 1.

Descriptive Statistics by Disability Condition.

	Without disabilities (n = 12 092)	With disabilities (n = 991)	All (n = 13 083)
Categorical variables	n (%)	n (%)	n (%)
ER visit
Not visited	10 949 (90.55)	828 (83.55)	11 777 (90.01)	χ²(1) = 49.88*
Visited	1143 (9.45)	163 (16.45)	1306 (9.98)	χ²(1) = 49.88*
Unmet needs
No unmet needs	10 649 (88.07)	812 (81.94)	11 461 (87.60)	χ ²(1) = 31.68*
Unmet needs	1443 (11.93)	179 (18.06)	1622 (12.40)	χ ²(1) = 31.68*
Gender
Male	5407 (44.72)	529 (53.38)	5936 (45.37)	χ ²(1) = 27.75*
Female	6685 (55.28)	462 (46.62)	7147 (54.63)	χ ²(1) = 27.75*
Continuous variables	M (SD)	M (SD)	M (SD)	t-test
Chronic disease	1.88 (2.24)	3.81 (2.74)	2.03 (2.34)	–25.58*
Age (years)	52.91 (17.92)	66.76 (15.31)	53.96 (18.11)	–23.63*

Note. Differences between conditions were evaluated using chi-square tests for categorical variables and t-tests for continuous variables; Chronic disease ranges from 0 to 16. Age ranges from 18 to 101.

M = mean; SD = standard deviation.

P < .001.

Path Analysis

Our analysis shows a significant association between disability and ED visits mediated by unmet healthcare needs and chronic disease. The results of the path analysis with the standardized regression coefficients and direct, indirect, and total effects are presented in Figure 2 and Table 2. Having a disability was associated with a 7.5% increase in the probability of ED visits. There were no direct effects of unmet healthcare needs on ED visits. Disability had a significant direct effect on unmet healthcare needs (β = .04, P ≤ .001) and chronic diseases (β = .10, P ≤ .001). The results indicated that disability indirectly affects ED visits mediated with chronic conditions (β = .018, P ≤ .001). However, there was no mediating effect of unmet healthcare needs between disability and ED visits. Unmet healthcare needs appear to indirectly influence ED visits (β = .004, P < .001) mediated with chronic disease but not directly on ED visits.

Figure 2.

Path diagram for the effects of disabilities on ED visits (*P≤.05, **p≤.01, ***p≤.001)

Table 2.

Standardized Effect Sizes for Mediated Relationships.

Effects	β	SE
Effects from disability to ER visits
Disability → Unmet medical needs → Chronic disease → ER visits	.000^*	0.000
Disability → Chronic disease → ER visits	.018^***	0.002
Disability → Unmet medical needs → ER visits	.000	0.001
Total indirect	.018^***	0.002
Direct	.039^**	0.014
Total effect	.075
Effects from unmet medical needs to ER visits
Unmet medical needs → Chronic disease → ER visits	.004^***	0.001
Direct	.012	0.015
Total effect	.016
Effects from disability to chronic disease
Disability → Unmet medical needs → Chronic disease	.001^*	0.000
Direct	.100^***	0.009
Total effect	.101

P ≤ .05. **P ≤ .01. ***P ≤ .001.

Note. Β = standardized parameter estimate; CI = confidence interval; ER = emergency room.

Additionally, our results indicated that respondents of older age were more likely to have experienced unmet healthcare needs, had more chronic diseases, and had visited EDs. The female respondents were more likely to have experienced unmet healthcare needs and have more chronic diseases but less likely to visit EDs.

Discussion

This study aimed to investigate the pathways by which disability, unmet healthcare needs, and chronic diseases were associated with ED visits. This study confirmed that disabilities were directly and indirectly associated with ED visits, mediated by unmet healthcare needs and the number of chronic diseases. These findings support the association between disability and ED utilization^4,6,7 and extend previous research by suggesting underlying mechanisms.

Specifically, people with disabilities reported higher unmet healthcare needs, and those with higher unmet healthcare needs reported more chronic diseases associated with increased ED utilization. In addition to the findings from previous studies on each pathway between these variables, our study found that the multiple pathways that disabilities indirectly impact ED visits.

Regarding the pathway between disabilities and unmet healthcare needs, this study found that disability was significantly associated with unmet healthcare needs. And people with disabilities significantly had more events of having unmet healthcare needs than people without disabilities (11.93% and 18.06%, consecutively). Previous studies reported barriers to access to care that people with disabilities may experience. These barriers include physical inaccessibility to clinics and hospitals (eg, clinics not accessible with wheelchairs, limited public transportation, and lack of caregivers who can accompany people with disabilities to the medical facilities).^28,29 People with disabilities also have barriers to preventive care such as general health check-ups and screening because screening machines (eg, mammography, chest X-ray, checking weight) are often not designed for people with disabilities.

These unmet healthcare needs due to a lack of economic and social support, such as unaffordable medical costs, difficulties in mobility, or not having a person to help communicate,¹⁵ in turn, could be related to the onset of chronic diseases, leading to ED visits. Pantell et al reported that factors such as poverty, infrequent exercise, and education level were associated with earlier onset of hypertension and diabetes.³⁰ Similarly, Vennu et al reported that social determinants of health, such as education level, unemployment, and annual income, were associated with chronic diseases such as arthritis, diabetes, and chronic obstructive pulmonary disease.³¹ Another study by Friedman also reported that people with intellectual and developmental disabilities with more social determinant outcomes, such as economic stability, education, neighborhood, and built environment, were more likely to visit emergency departments.³² Another study also reported that Medicare beneficiaries with disabilities were more likely to visit EDs due to non-emergent and preventable causes, which could have been taken care of in ambulatory care settings, than non-disabled beneficiaries.³³

Even though the pathway between disability and ED visits mediated with unmet healthcare needs and chronic disease was significant, interestingly, unmet healthcare needs did not directly influence ED visits nor mediate between disability and ED visits among the study participants. This means that the variable of unmet healthcare need itself was not associated with ED visits. Still, unmet healthcare needs and chronic diseases together would be more likely to be associated with ED visits. Based on previous studies, it could be inferred that frequent ED users usually have multiple health problems, including chronic diseases, many of which are ambulatory care-sensitive conditions (ACSC). These underlying diseases may increase ED visits, even after getting medical help outside the ED.^4,34,35 Another study on the analysis of ED use in the Veterans Affairs system reported that veterans used ED frequently, even with easy access to outpatient services in coordinated care systems.⁷ This implies that EDs provide certain aspects of healthcare services that may not be available in outpatient settings. For example, most outpatient clinics are open only during regular business hours, limiting access to care for people with disabilities with urgent care needs.

While barriers to access to care among people with disabilities (eg, inaccessibility of buildings or facilities due to immobility) are widely acknowledged, the significant association between disability and ED visits suggests that interventions or programs aimed at reducing ED visits will not be successful without understanding the unique healthcare needs of people with disabilities. People with disabilities often need emergent healthcare due to chronic conditions, regardless of their regularly provided primary health care. For example, people with spinal cord injuries have frequent urinary tract infections and bladder problems, leading them to be hospitalized or visit ED more frequently.^36,37 In this sense, it is vital to discern between health conditions requiring ED visits that can be addressed in alternative ways, such as homecare services. If homecare services are available, people with disabilities can get needed health care without visiting EDs. Schamess et al found declines in the use of ED and hospitals among people with multiple chronic conditions and disabilities after receiving home-based primary care. Home-based primary care reduces physical barriers to obtaining primary care without delays, especially for people with limited mobility, by providing symptom management, prompt response to acute symptoms and health crises, and medication management at home.

Overall, these findings have implications for public health professionals and policymakers. People with disabilities have unique health problems due to the types and severity of disabilities, along with chronic conditions. Improving access to primary health to reduce unmet healthcare needs and prevent chronic disease management is critical to people with disabilities. In Korea, the Ministry of Health and Welfare has been implementing pilot projects of providing team-based healthcare by physicians or nurses for people with severe disabilities.³⁸ The services include assessing, planning, and evaluating health status, health-related behaviors, and diseases and providing education and counseling via phone calls or home visits.³⁸ This study supports this pilot project’s potential to reduce barriers for people with limited mobility and improve access to care that can be handled with home visiting care instead of visiting EDs. A study investigating the demand for this project reported that having chronic diseases and an unmet need for medical care was significantly related to a higher demand for the project among people with disabilities.³⁹ When designing a program for people with disabilities, considering the need for home-visiting services can reduce the barriers to care and unnecessary ED visits, which can be an economic burden to the healthcare system.³³

Future studies need to explore the reasons and causes of ED visits among people with disabilities by their different types of disabilities. This study found that the disability itself was the leading cause of ED visits; therefore, it is essential to understand what kind of health problems people with disabilities have required more frequent ED visits. Case studies or in-depth interviews can be used to understand the barriers and challenges that people with disabilities face. This study and further in-depth qualitative research will inform developing policies and public health programs to help people with disability to reduce ED visits and manage their health before their conditions extend to the level required to visit EDs.

Limitations

Several limitations are important to consider when interpreting these findings. First, the cross-sectional study design did not conclude the causal relationship between disabilities, unmet healthcare needs, and chronic diseases. Unlike our hypothesis, the causal relationships between variables could be reversed. For example, unmanaged diabetes can damage the retina’s blood vessels, resulting in diabetic retinopathy, which can cause visual loss.⁴⁰ However, given our study purpose and hypotheses, we assumed the current direction for our analysis. In addition, we could not investigate the association between different types of disabilities and ED visits due to the complexity of the analysis we used. Respondents who reported disabilities in this study included 15 different kinds of disabilities, and each type of disability had different characteristics in terms of healthcare and social needs. For example, a study by Bhatnagar et al reported that veterans with lower-limb amputations have a higher risk for cardiovascular diseases, such as type 2 diabetes and high blood pressure, due to vascular changes,⁴¹ leading to a higher demand for care for chronic diseases than those with other types of disabilities. Also, people with mobility limitations would have more barriers to accessing care related to unmet healthcare needs. Future studies need to examine these relationships by the specific types of disabilities.

Conclusions

This study used the national KHPS dataset to explore pathways between disabilities and ED visits. We found a strong association between disability and ED visits mediated by unmet healthcare needs and chronic diseases. Interventions and public health programs addressing people with disabilities should consider this underlying mechanism to improve health for these populations.

Footnotes

Acknowledgements

Not applicable

Author’s Note

Jae-Hyun Park is also affiliated to WeDreamOn, Suwon, Gyeonggi-do, Korea.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI20C1073)

Ethical Consideration

Ethical review and approval were waived for this study by the Samsung Medical Center Institutional Review Board because it was a secondary data analysis of an anonymous sample that did not include any information to identify the survey participants (SMC202005065).

ORCID iD

Seungeun Park

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