title: Racial disparities in emergency department length of stay for admitted patients in the United States.
abstract: OBJECTIVE
  Recent studies have demonstrated the adverse effects of prolonged emergency department (ED) boarding times on outcomes. The authors sought to examine racial disparities across U.S. hospitals in ED length of stay (LOS) for admitted patients, which may serve as a proxy for boarding time in data sets where the actual time of admission is unavailable. Specifically, the study estimated both the within- and among-hospital effects of black versus non-black race on LOS for admitted patients.
  
  
  METHODS
  The authors studied 14,516 intensive care unit (ICU) and non-ICU admissions in 408 EDs in the National Hospital Ambulatory Medical Care Survey (NHAMCS; 2003-2005). The main outcomes were ED LOS (triage to transfer to inpatient bed) and proportion of patients with prolonged LOS (>6 hours). The effects of black versus non-black race on LOS were decomposed to distinguish racial disparities between patients at the same hospital (within-hospital component) and between hospitals that serve higher proportions of black patients (among-hospital component).
  
  
  RESULTS
  In the unadjusted analyses, ED LOS was significantly longer for black patients admitted to ICU beds (367 minutes vs. 290 minutes) and non-ICU beds (397 minutes vs. 345 minutes). For admissions to ICU beds, the within-hospital estimates suggested that blacks were at higher risk for ED LOS of >6 hours (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.01 to 2.01), while the among-hospital differences were not significant (OR = 1.08 for each 10% increase in the proportion of black patients, 95% CI = 0.96 to 1.23). By contrast, for non-ICU admissions, the within-hospital racial disparities were not significant (OR = 1.12, 95% CI = 0.94 to 1.23), but the among-hospital differences were significant (OR = 1.13, 95% CI = 1.04 to 1.22) per 10% point increase in the percentage of blacks admitted to a hospital.
  
  
  CONCLUSIONS
  Black patients who are admitted to the hospital through the ED have longer ED LOS compared to non-blacks, indicating that racial disparities may exist across U.S. hospitals. The disparity for non-ICU patients might be accounted for by among-hospital differences, where hospitals with a higher proportion of blacks have longer waits. The disparity for ICU patients is better explained by within-hospital differences, where blacks have longer wait times than non-blacks in the same hospital. However, there may be additional unmeasured clinical or socioeconomic factors that explain these results.
authors.affiliation: Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA. pinesjes@uphs.upenn.edu
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Pines
authors.forename: A
authors.initials: A
authors.lastname: Russell Localio
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
mesh_terms: D000293:Adolescent; D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D003441:Crowding; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010343:Patient Admission / Q000706:statistics & numerical data*; D010360:Patient Transfer / Q000706:statistics & numerical data; D012737:Sex Factors; D013997:Time Factors; D014481:United States; D055815:Young Adult