The emergency department as a pathway to admission for poor and high-cost patients
R. S. Stern, J. S. Weissman and A. M. Epstein
Department of Dermatology, Beth Israel Hospital, Harvard Medical School, Boston, MA 02215.
BACKGROUND.--To determine the importance of the emergency department as the
means of access to the hospital for the poor and the fiscal implications of
providing these services, we examined the relationship between patients'
socioeconomic status and admission via the emergency department. We also
determined the association between entering the hospital via the emergency
department and hospital resource use. METHODS.--We conducted a study of
20,089 patients admitted to five Massachusetts hospitals (three community,
two tertiary care) during a 6-month period. We determined the proportions
of patients within various socioeconomic and disease groupings who entered
through the emergency department. We compared length of stay and charges
for patients admitted through the emergency department with those for
patients admitted through other routes. RESULTS.--Overall, 51% of patients
entered via the emergency department. Elderly patients (age greater than 65
years; odds ratio, 1.87) and patients with lower socioeconomic status as
measured by income, occupation, and education (odds ratios, 2.38, 1.47, and
1.69, respectively) were more likely to enter the hospital via the
emergency department than other patients. After adjustment for diagnosis
related group, severity as measured by DRGSCALE, and socioeconomic status
as measured by income, and excluding outliers, patients admitted via the
emergency department stayed 27% longer and incurred 13% higher charges than
other patients (P less than .001). CONCLUSIONS.--Our data indicate that
patients with lower socioeconomic status are more likely than other
patients to use the emergency department as their means of access to the
hospital and that patients admitted via the emergency department use far
more resources than patients in the same diagnosis related group admitted
by other means. Hospitals that make emergency department services more
available may be more likely to hospitalize socioeconomically disadvantaged
patients and may be at a substantial financial disadvantage under per-case
reimbursement systems such as Medicare.
