Association of emergency department length of stay with safety-net status.
BACKGROUND
Performance measures, particularly pay for performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients.


OBJECTIVE
To describe emergency department (ED) compliance with proposed length-of-stay measures for admissions (8 hours or 480 minutes) and discharges, transfers, and observations (4 hours or 240 minutes) by safety-net status.


METHODS
The 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data were stratified by safety-net status (Centers for Disease Control and Prevention definition) and disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals (90.2% unweighted response rate) and 34 134 patient records. Visits were excluded for patients younger than 18 years, missing length-of-stay data or dispositions of missing, other, left against medical advice, or dead on arrival. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Multivariable analyses determined associations with length-of-stay measure compliance.


METHODS
Emergency Department length-of-stay measure compliance by disposition and safety-net status.


RESULTS
Of the 72.1% ED visits (N = 24 719) included in the analysis, 42.3% were to safety-net EDs and 57.7% were to non-safety-net EDs. The median length of stay for safety-net was 269 minutes (interquartile range [IQR], 178-397 minutes) for admission vs 281 minutes (IQR, 178-401 minutes) for non-safety-net EDs; 156 minutes (IQR, 95-239 minutes) for discharge vs 148 minutes (IQR, 88-238 minutes); 355 minutes (IQR, 221-675 minutes) for observations vs 298 minutes (IQR, 195-440 minutes); and 235 minutes (IQR, 155-378 minutes) for transfers vs 239 minutes (IQR, 142-368 minutes). Safety-net status was not independently associated with compliance with ED length-of-stay measures; the odds ratio was 0.83 for admissions (95% CI, 0.52-1.34); 1.03 for discharges (95% CI, 0.83-1.27); 1.05 for observations (95% CI, 0.57-1.95), 1.30 for transfers (95% CI, 0.70-2.45]); or subcategories except for psychiatric discharges (1.67, [95% CI, 1.02-2.74]).


CONCLUSIONS
Compliance with proposed ED length-of-stay measures for admissions, discharges, transfers, and observations did not differ significantly between safety-net and non-safety-net hospitals.
Department of Emergency Medicine, University of California, San Francisco, 505 Parnassus Ave, PO Box 0208, San Francisco, CA 94143, USA. christopher.fee@ucsf.edu
Christopher
C
Fee
Helen
H
Burstin
Judith H
JH
Maselli
Renee Y
RY
Hsia
D000328:Adult; D000368:Aged; D004469:Economics, Hospital; D004636:Emergency Service, Hospital / Q000191:economics* / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence; D006761:Hospitals / Q000145:classification*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D017057:Medically Uninsured; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data; D012052:Reimbursement, Incentive; D014481:United States; D055815:Young Adult