Low-Value Use and Emergency Department Usage Among Bhutanese Refugees Resettled in the United States

Background and Purpose

This presentation will explore factors underlying the relatively high rate of emergency department usage among Bhutanese refugees resettled in one city in the United States.  The overuse of hospital-based care and underuse of primary care, described as "low-value care,” poses negative consequences for patients and the health care system (Kangovi et al, 2013).  Research demonstrates that emergency department (ED) usage for non-emergency conditions is an important indicator of low-value care.  

Recent studies demonstrate that refugees may have poorer health and higher rates of chronic disease relative to other immigrant groups and U.S. peers. Major health concerns among refugee populations include: tuberculosis, parasites, respiratory tract infections, hepatitis, and mental health conditions. The relative overuse of ED and underuse of primary care among refugees may suggest structural problems in primary and preventative care access. 

Methods

Qualitative grounded theory methods were employed to examine health care utilization among Bhutanese refugees, who are beyond the period of Refugee Medical Assistance (RMA), resettled in one U.S. city.  This study utilized semi-structured intensive interviews with 30 Bhutanese refugee adults; a total of 71 refugee individuals were encountered during data collection. Interviews were audio-recorded and transcribed; coding was undertaken using NVivo.

Results

The data indicate that ED usage was relatively high among refugee respondents. Findings demonstrate that difficulty with transportation, communication, and health insurance prevented refugees’ access to primary care and health resources.  28% of participants reported ED usage for a health condition within the past year—higher than CDC national data (2015).  67% of respondents reported that at least one household member utilized ED care.  Respondents described the ease of ED usage relative to primary care in the post-RMA period as the primary reason for ED usage. 

Conclusions & Implications

The high rate of emergency care usage and low rate of primary care usage align with findings from other health studies on vulnerable and low income populations (CDC, 2015).  All respondents in the study described health services sought in the post-RMA period as illness-related care.  No participants reported utilizing preventative or custodial care beyond that which may have been provided during mandatory domestic screenings in the RMA period. Studies demonstrate that low SES patients are twice as likely as high-SES patients to seek ED care and 45% less likely to use ambulatory and preventive care (Kangovi et al, 2013).  Emergency departments are seeing an increase in the number of patients. A key reason for this trend may be that patients cannot gain timely access to a primary care provider. People commonly described the hospital as being more available to meet their needs than ambulatory care. Studies suggest that factors beyond insurance shape preferences for hospital-based versus ambulatory care. This study may carry broader implications for social work in health settings, health economics, and health policy for refugees.