The Right to Be Sick: Economic and Racial Differences for Visit Verification Note Need in Urban Emergency Departments

In the United States, a notable proportion of emergency department (ED) visits may be driven by non-medical administrative needs, such as obtaining work verification notes to justify absences from employment. While international data suggest socioeconomic and racial disparities in who must provide such documentation, little is known about how these dynamics play out in US EDs. We aimed to characterize demographic, socioeconomic, and clinical factors associated with receiving work notes in an urban emergency setting.

We conducted a retrospective study of patients aged 14–66 years who were discharged from a Massachusetts community ED between July 1, 2021, and January 31, 2022. Receipt of a work note served as a proxy for need. Demographic and clinical characteristics were compared between patients who did and did not receive notes using χ² tests. Access to urgent care was proxied using a spatially-explicit drive time model. Multivariable logistic regression assessed the association between Area Deprivation Index (ADI), Emergency Severity Index (ESI), urgent care drive times, and work note receipt, adjusting for age. Geographically weighted regression was performed to assess spatial heterogeneity.

Of 9,879 eligible patients, 1,105 (11%) received a work note. Compared to those who did not, patients receiving notes were more likely to be Black (35% vs. 25%), Hispanic (42% vs. 33%), of prime working age (23–39 years), and to have lower educational attainment (p<0.001 for all). They were more likely to present with lower acuity (ESI 4–5: 45% vs. 32%, p<0.001). Logistic regression showed that each one-point increase in ADI was associated with 1.09 higher odds of receiving a work note (95% CI 1.05–1.13, p<0.001), and lower acuity was associated with 1.76 higher odds compared to higher acuity visits (95% CI 1.55–2.00, p<0.001). Urgent care drive time was not significantly associated with work note receipt. Geographic heterogeneity was modest.

Patients with higher social vulnerability, lower clinical acuity, and from racially and economically marginalized groups were more likely to receive work verification notes in the ED. These findings highlight how workplace documentation requirements may perpetuate structural inequities and contribute to avoidable ED utilization, suggesting opportunities for policy interventions to standardize or eliminate unnecessary verification requirements.