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to meet the needs of sub-populations with acquired or
developmental disability, substance abuse and behavioral
health disorders.
In 2015, ED utilization by Californians was notably lower
at 364 per thousand. Without formal risk adjustment,
some of the variation may be attributed to California’s
slightly younger population (35 v. 37.8-40.3). The popula-
tion of California is also more diverse than the US overall:
Hispanics (39%) now exceed white non-Hispanics (just
under 38%). Asians are the third largest ethnic group in
California (13%] and African Americans are the fourth (4).
The US Census Bureau estimated the total population of
California at 39144818 persons in 2015 (5).
Of interest, per capita ED utilization in California was
lower before expansion of public and private health insur-
ance under the Affordable Care Act (ACA) in 2014. This
behavioral effect has been attributed to new beneficiaries
of public and private coverage. By 2015 less than 10% of
California residents lacked health insurance coverage (6),
of whom 1.5 million were ineligible due to their immigra-
tion status (7).
OVERVIEW OF CALIFORNIA EMERGENCY CARE SYSTEM
In 2015, the Office of Statewide Health Planning and
Development [OSHPD] reported there were 7558 treat-
ment stations in 328 public and private hospitals with
ED’s (8). That year there were 12367716 visits to Cali-
fornia’s ED’s who were discharged following treatment,
and another 1885374 visits that required hospitalization
statewide.
Prehospital Care Administration
The three-digit 911 standard was adopted by the US tele-
phone industry in 1968. Public Safety Answering Points
to coordinate police, fire, and emergency medical service
(EMS) responses were widely implemented by local govern-
ments over the following decade. Funding for the 911
communications infrastructure is covered by surcharges
on telephone users. Present-day residents of California
have ubiquitous access to pre-hospital emergency medical
services as a result. In 2013, the California Ambulance
Association reported that 3600 ambulances were oper-
ating in California; 74% by 170 private companies and
26% by public agencies, primarily fire departments. The
association estimated 2.7 million ambulance transports
in California during 2013, almost 90% of which were for
emergency medical response or interfacility transport
requiring medical care (9).
Ambulance response to EMS dispatch is structured by local
government agencies. Contracts areperiodically opened
for competitive bidding between ambulance companies.
Agencies typically include performance benchmarks for
response times for Basic Life Support (BLS) and Advanced
Life Support (ALS) calls and other quality indicators. In all
cases, service agreements offer geographic exclusivity for
single-incident calls to prevent unnecessary duplication
of pre-hospital emergency transportation. Mutual aid
agreements define disaster or mass-casualty situations
when multiple ambulance service providers are needed.
In metropolitan areas, paramedics are extensively trained
above ALS level and are usually employed by fire depart-
ments. All fire personnel are typically certified at BLS
level and act as first-responders to EMS calls. In some
TABLE 1. EMERGENCY DEPARTMENT VISITS AND UTILIZATION PER THOUSAND
FOR CANADA, ENGLAND, UNITED STATES, AND CALIFORNIA - 2015
POPULATION
MEDIAN AGE
ED VISITS
ED UTILIZATION
PER 1000 PEOPLE
CANADA
35749600
40.5
15873016
444
ENGLAND
54000000
40
22659980
420
UNITED STATES
316500000
37.8
133600000
423
CALIFORNIA
39144818
35
14253090
364
Notes: Age, population estimates came from public data sets. For Canada, Statistics Canada. For England, the United Kingdom National Center for Statis-
tics. For US and California, the US Census Bureau. The 2013 US population was used for this table because it was the most recent year that national data
on ED visits was available from the American Hospital Association. ED utilization estimates for Canada were from the National Ambulatory Care Reporting
System; for England, the House of Commons Library. California ED visits were from the Office of Statewide Health Planning and Development.
[THE ACUTE CARE CONTINUUM IN CALIFORNIA -William Wesley Fields MD FACEP.]