Article, Emergency Medicine

Variation in hospital admission rates between a tertiary care and two freestanding emergency departments

a b s t r a c t

Background: Recently, freestanding emergency departments (FSEDs) have grown significantly in number. Critics have expressed concern that FSEDs may increase Healthcare costs.

Objective: We determined whether admission rates for identical diagnoses varied among the same group of phy- sicians according to clinical setting.

Methods: This was a retrospective comparison of adult admission rates (n = 3230) for chest pain, chronic ob- structive pulmonary disease (COPD), asthma, and congestive heart failure (CHF) between a hospital-based ED (HBED) and two FSEDs throughout 2015. Frequency distribution and proportions were reported for categorical variables stratified by facility type. For categories with cell frequency less or equal to 5, Fisher’s Exact test was used to calculate a P value. Chi square tests were used to assess difference in proportions of potential predictor variables between the HBED and FSEDs. For continuous variables, the mean was reported and Student’s t-test assessed the difference in means between HBED and FSED patients. Multivariate logistic regression analyses were performed to estimate the unadjusted and adjusted prevalence odds ratio with 95% confidence interval (CI) for patient disposition outcomes associated with type of ED facility visited.

Results: Of 3230 patients, 53% used the HBED and 47% used the FSED. Patients visiting the HBED and FSED varied significantly in gender, Acuity levels, diagnosis, and number of visits. Age was not significantly different between facilities. Multivariable adjusted estimated prevalence odds ratio for patients admitted were 1.2 [95%CI: 1.0-1.4] in the HBED facility compared to patients using FSEDs.

Conclusion: In our healthcare system, FSEDs showed a trend towards a 20% lower admission rate for chest pain, COPD, asthma and CHF.

(C) 2017

  1. Introduction

Freestanding emergency departments (FSEDs) have grown rapidly over the past decade. Depending on the state, FSEDs can be operated in- dependently or as part of a hospital system. Hospital-Based FSEDs are run by hospitals and must be licensed by the state and adherent to Medicare Conditions of Participation. They are financially and clinically integrated with the affiliated hospital and located within a 35-mile radi- us. They are compliant with all of the requirements of their parent hospital’s ED, including 24/7 care and EMTALA obligations. Independent

? Prior presentations: National Association of Freestanding Emergency Centers; Houston, Texas, June 2016 , September 2017.

* Corresponding author at: Akron General Medical Center, 1 Akron General Ave., Akron, OH 44307, United States.

E-mail address: [email protected] (E.L. Simon).

Freestanding Emergency Centers/Departments (IFECs) are facilities owned and operated by non-hospital for-profit entities. IFECs are simi- lar to hospital-based FSEDs in terms of services they offer. They are not considered provider-based emergency departments (EDs) and are not recognized by the Center for Medicare and Medicaid Services (CMS) as emergency departments; because of this, these facilities are not bound by federal ED regulations and do not have to comply with EMTALA, although many do.

FSEDs have increased by 62% between 2009 and 2015 [1,2,3]. Now that there are over 360 FSEDs in operation across the United States (U.S.), some have questioned the effect of these facilities on patient care [4]. Approximately a quarter of all acute care outpatient visits occur in U.S. emergency departments and that number continues to grow [5].

Perhaps the most significant financial decision that an emergency physician makes is the choice to admit a patient [6]. Called “the

https://doi.org/10.1016/j.ajem.2017.10.066

0735-6757/(C) 2017

most expensive decision in US healthcare” [7], hospital admissions com- ing through the emergency department (ED) have continued to rise and represented 81.8% of all unscheduled hospital admissions in 2013 [8]. According to a recent analysis, admissions from the ED account for 8.3% of National health expenditures [9]. Another study revealed inpa- tient care accounts for 31% of national healthcare spending [6]. Sabbatini found that among 961 hospital-based EDs, admission rate was 15.4% and the average charge was $34,826 per admission [10]. Another study evaluated 8303 ED encounters and found a median charge of

$1233 and a mean charge of $2168 for outpatient conditions in the ER [11]. Variations in clinical practice and the medical legal environment has led to large discrepancies in the decision to admit, with some facil- ities having more than a 6-fold difference for comparable cases [12].

There has even been variation between EPs at the same facilities, with some EPs admitting as little as 38% of patients and others admitting as much as 79%, even though the physicians have seen comparable pa- tients [13]. Admission agreement between EPs could be as low as 52% in some cases, leading some to conclude that the decision to admit is de- pendent on EP personality and practice style [13].

Clearly, there are factors outside of a patient’s presenting condition that affect the EP’s decision to admit. Convenience, cost of transport, availability of outpatient follow-up, need to “turn” a bed for patients in the waiting room, pressure from metric driven reimbursement, time to reevaluate and perform serial exams or labs, social support, and the patient’s primary care support may also influence an EP’s choice. While studies have explored the differences in admission rates and acuity levels at various facilities [12,14,15], none have compared ad- mission rates between a HBED and FSEDs for the same diagnosis.

Critics of FSEDs have remarked that they see little differences in the capabilities and quality of care between the two. However, they are con- cerned with the competition that is brought from FSEDs for the “paying, urgent-care patients” so that HBEDs can continue to afford to provide care for all patients. They feel the playing field is already uneven and marketing of non-hospital-based FSEDs makes that challenge more dif- ficult [16]. Others criticize FSEDs and the care they provide because state policies vary widely with no standard requirement for location, staffing patterns, or clinical capabilities. Some feel consistent state regulations are needed [17].

We chose to explore the potential difference between the admis- sion decisions occurring in FSEDs and HBEDs due to multiple reports that the admission rates differ between these types of facilities [18, 19]. Some thought leaders believe that FSEDs are a novel healthcare model that could curb healthcare costs through the process of reduc- ing hospital admissions [20]. The difficulty of addressing this issue is confounded by the fact that HBEDs and FSEDs may see different pa- tient populations in terms of both breadths of conditions as well as Acuity of patients. Thus, our study objective was to determine whether patient admission rates for the same diagnosis, with similar acuity, varied for the same group of physicians according to the clin- ical setting.

We evaluated whether admission rates of patients vary between FSEDs and a HBED after controlling for type of health conditions, acuity level, gender and age. If variation exists, it would warrant further study on whether health care costs are ultimately impacted by the growth of FSEDs.

  1. Materials and methods

This was a retrospective comparison of admission rates between an urban tertiary care hospital-based ED (HBED) and two FSEDs within the same health system. Data were collected from the HBED and its two FSEDs during 2015. All physicians were board certified by American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine. All physicians were scheduled to work at the HBED and the FSEDs at relatively equal shift percentages. The distance between the HBED and FSEDs were 16 miles and

4.5 miles respectively. The EDs had the same overall hospital admin- istration and utilized the same Treatment protocols. Each ED had its own medical director. FSED 1 and 2 had full lab service available, which included blood banking with O-Negative Packed red blood cells and fresh frozen plasma. Both FSEDs had radiology services that included dedicated CT and x-ray availability. Ultrasound was available but required calling in an ultrasound technician at all hours at FSED 1 for a formal ultrasound. FSED 2 had an ultrasound technician available from 8 am to 5 pm on weekdays and on call for other hours. FSED 1 had no MRI capabilities; however FSED 2 had an onsite MRI available from 8 am to 5 pm.

The HBED is a tertiary care facility with annual volume of 64,296 in 2015. FSED 1 is a hospital owned ED with annual volume of 17,948 in 2015. FSED 2 is also hospital owned with annual volume of 26,819 pa- tients in 2015. FSED 1 and FSED 2 take ambulances and all patients in- cluding Medicare and Medicaid patients.

Data were gathered using the electronic medical record Medhost version 4.4 for metrics at all facilities. The analysis for our study was re- stricted to adults aged 18 years or above (n = 3230). Data included pa- tient age, gender, triage acuity level, diagnosis, and disposition. Patients under 18 and those that expired were excluded from the study. Patients that eloped or left against medical advice (LAMA) were categorized as “discharged” and patients transferred to outside Hospital systems were considered “admitted”. We looked at the 20 most common diag- nosis-Acuity groups and found sample sizes were only adequate for chronic obstructive pulmonary disease (COPD), chest pain, asthma and congestive heart failure (CHF). All acuity levels were collected and categorized via the Triage emergency severity index. The ESI was calcu- lated by the potential use of resources. Level 1 required “Resuscitation” for stabilization and was determined to be critical. Level 2 was “Emer- gent” and was high risk. Level 3 was “Urgent” and determined to likely require more than one resource to treat at triage. Level 4 was “Semi-Ur- gent” and predicted to need only one resource for treatment. Level 5 was “Non-Urgent” and predicted at triage to require no other resources for treatment other than a physician evaluation. All 2015 data was fil- tered to determine admission percentage for each facility based on dis- position diagnosis.

Our primary factor of interest (predictor) was facility type (HBED versus FSEDs). potential confounding variables used for the study were, age, sex, acuity level, and type of diagnosis. Outcome of interest was patient disposition (admitted versus discharged). Age was categorized into three groups: a) 18 to 35 years; b) 36 to 54 years; c) 55 and above. For the multivariable analysis, the sample was restricted to acuity levels 2, 3 and 4 because of small sample size in acuity level 1 and 5. Total sample size used for the multivariate analysis was 1371.

  1. Statistical analyses

Frequency distribution and proportions were reported for categori- cal variables stratified by facility type that patients visited (HBED versus FSEDs) and patient disposition (admitted versus discharged). Chi square tests were used to assess the difference in proportions of poten- tial predictor variable between the HBED and FSEDs. For categories with cell frequency less or equal to 5, Fisher’s Exact test was used to calculate P value. For continuous variables, the mean [standard deviation (SD)] was reported and Student’s t-test was used to access the difference in means between HBED patients and FSED patients. Significance of the test was determined using ? = 0.05 as a cutoff. Multivariate logistic re- gression analyses were performed to estimate the unadjusted and ad- justed prevalence odds ratio (OR) with 95% confidence interval (CI) for patient disposition outcomes associated with type of ED facility vis- ited by patients. All analyses were conducted using SAS(R) 9.3 (SAS Insti- tute Inc., Cary, NC, USA). The Baylor College of Medicine Institutional Review Board approved this study as exempt.

Table 1

Socio demographic characteristics of Emergency Department (ED) patients stratified by type of facility visited (N = 3230).

Table 3 demonstrates the proportion distribution of patients’ acuity level by the type of diagnosis of the patients visiting different emergen- cy facilities. Levels 1, 4 and 5 reported lower number of cases compared

Variables Overall

N (%)

Type of ED facility N = 3230

P value

to levels 2 and 3. Only COPD patients reported significant difference be- tween acuity level for patients that presented to the HBED and FSEDs.

HBED 1708

(52.9)

FSED 1522

(47.1)

There was no significant difference in acuity level of patients visiting ei- ther the HBED or FSEDs for health conditions such as asthma, CHF and chest pain.

Age (Mean, +-SD) 57 (+-19) 58 (+-19) 57 (+-19) 0.319

Table 4 shows the unadjusted and multivariable adjusted prevalence

Number of visits (Mean,

+-SD)

2.8 (+-3) 1.7 (+-1.2) 3.9 (+-4) b 0.0001?

*

odds ratio for patient disposition outcomes with the type of ED facility used by patients. In the univariate analysis, the estimated prevalence

Acuity b 0.0001

Level 1 42 (1.3) 33 (2.0) 9 (0.6)

odds ratio for patients who were admitted was 1.3 [95% CI: 1.1-1.5] in

Level 2 1086

(34.3)

Level 3 1611

(50.9)

619 (37.5) 467 (30.8)

796 (48.3) 815 (53.8)

HBED facility when compared to patients using FSED. This association was marginally significant. In a multivariable regression analysis, where the model was adjusted for potential confounding factors, the es-

Level 4 409 (12.9) 192 (11.6) 217 (14.3)

Level 5 17 (0.5) 9 (0.5) 8 (0.5)

Diagnosis b 0.0001?

Asthma

473 (14.6)

268 (15.7)

205 (13.5)

CHF

544 (16.8)

350 (20.5)

194 (12.7)

COPD

689 (21.3)

386 (22.6)

303 (19.9)

Chest pain

1524

704 (41.2)

820 (53.9)

(47.2)

Age group (years) 0.699

18-35

474 (14.7)

245 (14.3)

229 (15.0)

36-55

987 (30.6)

516 (30.2)

471 (30.9)

56 or above

1769

947 (55.4)

822 (54.0)

Gender

(54.8)

0.006?

Female

1796

911 (53.3)

885 (58.1)

(55.6)

Male

1434

797 (46.7)

637 (41.8)

(44.4)

Note: SD: Standard Deviation; HBED: Hospital-Based Emergency Department; FSED: Free Standing Emergency Department; COPD: Chronic Obstructive Pulmonary Disease; CHF: Congestive Heart Failure.

Level 1: Resuscitated; Level 2: Emergent; Level 3: Urgent; Level 4: Semi-urgent; Level 5: Non-urgent.

* Significant P-values b 0.05.

  1. Results

The total sample size used for the study was 3230. Mean age of the study population was 57 (+-19) years. The average number of ED visits by patients was approximately 2.8 (+-3) visits (range: 1 to 27 visits). Table 1 reports descriptive statistics of overall study sample stratified by type of facility visited by the patients (HBED versus FSED). Of total 3230 patients, 53% used the HBED and 47% used the FSED. More than half of the patients who presented for ED services were female (56%) and fell within the age group 56 years or above (55%). Of the patients seen at the HBED, 37.5% were acuity level 2, 48.3% were acuity level 3, and 11.6% were acuity level 4. The remaining patients that presented to the HBED were level 1 or 5. FSEDs saw 30.8% of patient with acuity level 2, 53.8% with acuity level 3 and 14.3% with acuity level 4. The re- maining FSED patients were level 1 or 5. Patients visiting the HBED and FSEDs were significantly different in gender, acuity levels, health conditions diagnosed and number of visits to the facility. Age of the pa- tients was not significantly different between the HBED and FSEDs.

Table 2 reports descriptive statistics of overall study sample strati- fied by patient disposition. It also demonstrates the comparison of pa- tient disposition by type of facility patients visited. Of total 1708 patients who used HBED, 49% (n = 842) got admitted to hospital. Gen- der of the patients were not significantly different between admitted HBED patients and discharged HBED patients whereas patients were significantly different in their acuity level, health conditions diagnosed, age group and number of visits to HBED. Of total 1522 patients who used FSED, 42% (n = 645) were admitted to the hospital. There were significant differences between FSED patients in their acuity level, health conditions diagnosed, age group and number of visits to FSED.

timated prevalence odds ratio for patients who were admitted de- creased to 1.2 [95% CI: 1.0-1.4]. Thus, patients using HBED were 20% more likely to be admitted to hospital when compared to patients using FSED. However, this association showed a trend but was not found to be significant.

  1. Discussion

These results show that a patient who presented to our HBED trended towards a 20% higher likelihood of admission than if a similar patient presented to our hospital-based FSED. While these data cannot explain the causal nature of this trend, there are several possible explanations.

One prior study showed that having higher hospital occupancy rates, higher number of inpatient beds, being in an urban location, and having a level 1 or 2 trauma center were all associated with higher ED admis- sion rates [21]. Considering chest pain as an example, admitting a pa- tient for an inpatient cardiac stress test after the first negative set of cardiac markers might be quicker than holding a low-risk patient in the HBED for a second set of laboratory work and arranging an outpa- tient cardiac stress test. It might be much more feasible to perform the latter at a FSED.

Another theory is that patients in the waiting room provide the larg- est risk for the ED physician. In a busy HBED the physician that does not “turn” beds quickly can pose a risk to quality and patient satisfaction for the entire hospital system. Metrics driven on time sensitive data and pa- tient satisfaction may push ED physicians to make early dispositions. FSEDs tend to have lower volumes and shorter wait times. The pressure to “turn” patients quickly is not as profound allowing the physician time to arrange follow-up and perform longer work ups.

Patients sometimes prefer to come to FSEDs because the wait times at HBEDs are long. There are stories in the lay press that tell patients not to die while waiting in the ER [22]. Even documentary films have been made documenting this situation [23]. A study by one of the authors re- vealed that for a major health insurer in Texas, the prices paid for care at HBEDs vs. FSEDs were nearly identical [24]. Thus, the main driving fac- tor for patients to visit FSEDs over HBEDs is likely for convenience – ei- ther distance from home or shorter wait times – and not primarily due to financial reasons. Another study also evaluated hospital-based FSED and HBED length of stay for median time in waiting room, time from door to diagnostic evaluation by a qualified medical provider and treat- ment time for discharged patients. They found hospital-based FSED were faster than HBEDs for all three categories [25].

Until now, few have been able to capture the unintended conse- quences of quick admission dispositions in HBEDs. These admission de- cisions could potentially increase total healthcare costs. Given these data, third party payers might incentivize their patients to utilize hospi- tal-based FSEDs in order to decrease exposure environments that ap- pear to promote admission over outpatient management. However, there is also the potential cost of transport if a patient requires admis- sion to a HBED. As an area of future research, one could analyze

Table 2

Socio demographic characteristics of Emergency Department (ED) patients stratified by patient disposition. (N = 3230).

Variables

Overall

Type of ED facility

HBED

FSED

N = 1708

N = 1522

Admitted

Discharged

P value

Admitted

Discharged

P value

Admitted

Discharged

P value

N (%)

N (%)

N (%)

N (%)

N (%)

N (%)

1487 (46.0)

1743 (54.0)

842 (49.0)

866 (51.0)

645 (42.4)

877(57.6)

Age

634(+-17)

52 (+-18)

b 0.0001?

63 (+-17)

52 (+-18)

b0.0001?

66 (+-16)

51 (+-19)

b0.0001?

(Mean, +-SD)

Number of visits

3 (+-4)

2 (+-3)

b 0.0001?

4 (+-5)

3 (+-3)

b0.0001?

1 (+-1)

1 (+-1)

b0.0001?

(Mean, +-SD)

Acuity

b 0.0001?

b0.0001?

b0.0001?

Level 1

41 (2.8)

1 (0.06)

32 (3.9)

1 (0.1)

9 (1.4)

0 (0.0)

Level 2

681 (42.4)

468 (27.4)

359 (44.2)

260 (31.1)

259 (40.2)

208 (23.8)

Level 3

739 (50.8)

872 (51.0)

386 (47.5)

410 (48.9)

353 (54.8)

462 (52.9)

Level 4

56 (3.8)

353 (20.7)

33 (4.1)

159 (19.0)

23 (3.6)

194 (22.2)

Level 5

2 (0.14)

15 (0.9)

2 (0.2)

7 (0.8)

0 (0.0)

8 (0.9)

Diagnosis

b 0.0001?

b0.0001?

b0.0001?

Asthma

94 (6.3)

379 (21.7)

63 (7.5)

205 (23.7)

31 (4.8)

174 (19.8)

CHF

405 (27.2)

139 (8.0)

262 (31.1)

88 (10.2)

143 (22.2)

51 (5.8)

COPD

335 (22.5)

354 (20.3)

207 (24.6)

179 (20.7)

128 (19.8)

175 (19.9)

Chest pain

653 (43.9)

871 (50.1)

310 (36.8)

394 (45.5)

343 (53.2)

477 (54.4)

Age group (years)

b 0.0001?

b0.0001?

b0.0001?

18-35

75 (5.0)

399 (22.9)

57 (6.8)

188 (21.7)

18 (2.8)

211 (24.1)

36-55

389 (26.2)

598 (34.3)

230 (27.3)

286 (33.0)

159 (24.6)

312 (35.6)

56 or above

1023 (68.8)

746 (42.8)

555 (65.9)

392 (45.3)

468 (72.6)

354 (40.4)

Gender

0.0566

0.118

0.397

Female

800 (53.8)

996 (57.5)

433 (51.4)

478 (55.2)

367 (56.9)

518 (59.1)

Male

687 (46.2)

747 (42.9)

409 (48.6)

388 (44.8)

278 (43.1)

359 (40.9)

Note: SD: Standard Deviation; HBED: Hospital-Based Emergency Department; FSED: Free Standing Emergency Department; COPD: Chronic Obstructive Pulmonary Disease; CHF: Conges- tive Heart Failure.

Level 1: Resuscitated; Level 2: Emergent; Level 3: Urgent; Level 4: Semi-urgent; Level 5: Non-urgent.

* Significant P-values b 0.05.

independent FSEDs to understand if hospital affiliation impacts the like- lihood of admission.

The admission process from a HBED compared to a FSED can also be different. At the facilities studied, the admission process involved the same EMR, bed boards, and other processes with the exception of trans- port. At the FSED when using an ambulance service, there could be a delay in arrival to a hospital bed or challenges finding a bed at the accepting hospital if they are at capacity.

5.1. Limitations

There are several confounding variables that should be considered when interpreting the data. First, this study took place at a single hospi- tal system and results may differ among providers in other systems. Sec- ond, while the patient populations were comparable by complaint and acuity, it was discovered that this study lacks data such as information on patient socioeconomic characteristics (e.g. race and income level). There could be significant differences in socio-economic factors

between the HBED and the FSEDs which could be potential confounding factors affecting the outcome of interest. We were also unable to include a Charlson Co-morbidity Index or Elixhauser score. Since acuity does not always determine sickness, we were limited in our ability to determine if patients were sicker at the HBED or the FSED and whether that im- pacted the rate of admission measured.

Although not the focus of this study, we did review the insurance status of patients between both FSEDs and the HBED and found it to be similar (data not shown) however not including this data is a limita- tion. Small sample size is a limitation of the study, which may have af- fected the significance of the association. A larger sample size may have revealed a significant difference.

There can be inconveniences for patients that result from the deci-

sion to admit at a FSED. Since FSEDs are built for geographical proximity to the patient’s home, the patient and their family are likely to be further away from a hospital, leading to separation after admission. The patient also may face an ambulance cost when admitted from a FSED. These pa- tient-centric inconveniences could directly influence the EP’s decision,

Table 3

Proportion distribution of patients’ acuity level by the type of diagnosis of the patients visiting different emergency facility (Both HBED and FSED). (N = 3165a). Acuity Asthma (n = 466) CHF (533) COPD (675) Chest pain (1491)

Facility type

P valuea

Facility type

P valuea

Facility type

P valuea

Facility type

P valuea

HBED FSED

HBED FSED

HBED FSED

HBED FSED

N (%) N (%)

N (%) N (%)

N (%) N (%)

N (%) N (%)

Level 1

2 (100.0) 0 (0.0)

0.0957

12 (70.6) 5 (29.4)

0.2142

15 (93.7) 1 (6.25)

b 0.0001b

4 (57.1) 3 (42.9)

0.0657

Level 2

57 (67.1) 28 (32.9)

134 (67.7) 64 (32.3)

144 (65.7) 75 (34.2)

284 (48.6) 300 (51.4)

Level 3

130 (54.8) 107 (45.1)

183 (62.5) 110 (37.5)

189 (50.8) 183 (49.2)

294 (41.5) 415 (58.5)

Level 4

69 (50.7) 67 (49.3)

12 (48.0) 13 (52.0)

24 (36.9) 41 (63.1)

87 (47.5) 96 (52.5)

Level 5

3 (50.0) 3 (50.0)

0 (0.0) 0 (0.0)

1 (33.3) 2 (66.7)

5 (62.5) 3 (37.5)

Note: HBED: Hospital-Based Emergency Department; FSED: Free Standing Emergency Department; COPD: Chronic Obstructive Pulmonary Disease; CHF: Congestive Heart Failure. Level 1: Resuscitated; Level 2: Emergent; Level 3: Urgent; Level 4: Semi-urgent; Level 5: Non-urgent.

a Fisher’s Exact Test was used to calculate P value because of frequencies less or equal to 5 in some of the categories.

b Significant P-values b 0.05.

Table 4

Unadjusted and multivariable adjusteda estimates of prevalence odds ratio and 95% CI for type of ED facility used by patients associated with patient disposition.

Patient deposition

(Reference: discharged patients)

  1. Rapaport L. Health News. July 19, 2016. Are freestanding emergency rooms follow- ing the money? http://www.reuters.com/article/us-health-access-freestanding-er- idUSKCN0ZZ2PA. Accessed 2016 August 10.
  2. Schuur JD, Baker O, Freshman J, Wilson M, Cutler DM. Where do freestanding emer- gency departments choose to locate? A National Inventory and geographic analysis in three states. Ann Emerg Med 2017;69(4):383-92.
  3. Ruth S. Breaking News: Washington Legislator Seeks to Stall Freestanding ERs. Avail-

Diagnosis

Unadjusted OR

(95% confidence interval)

Adjusted OR

(95% confidence interval)

able from http://journals.lww.com/emnews/Fulltext/2012/04000/Breaking_News Washington_Legislator_Seeks_to2.aspx. Accessed 2016 Aug 10.

  1. Schuur J, Venkatesh A. The growing role of emergency departments in hospital ad- missions. N Engl J Med 2012;367:391-3.

Asthma 0.3 (0.2-0.4) 0.5 (0.3-0.6)

CHF 3.7 (2.9-4.6) 2.7 (2.1-3.4)

COPD 1.2 (1.0-1.4) 0.9 (0.7-1.1)

Chest pain Reference Reference

Acuity level

Level 2 8.3 (6.1-11.3) 5.2 (3.8-7.2)

Level 3 5.3 (3.9-7.2) 3.6 (2.6-4.9)

Level 4 Reference Reference

Gender

Male 1.1 (0.9-1.3) 1.0 (0.9-1.2)

Female Reference Reference

Age group (in years)

18 to 35 Reference Reference

36 to 55 3.6 (2.7-4.8) 2.7 (2.0-3.7)

56 or above 7.5 (5.8-9.9) 4.5 (3.3-5.9)

Facility type

HBED 1.3 (1.1-1.5) 1.2 (1.0-1.4)

FSED Reference Reference

Note: SD: Standard Deviation; HBED: Hospital-Based Emergency Department; FSED: Free Standing Emergency Department; COPD: Chronic Obstructive Pulmonary Disease; CHF: Congestive Heart Failure; OR: Odds Ratio.

Level 1: Resuscitated; Level 2: Emergent; Level 3: Urgent; Level 4: Semi-urgent; Level 5: Non-urgent.

a Adjusted for type of health condition diagnosed, acuity level, facility type, gender and age group.

but could also influence the patient to refuse admission. We removed patients that left against medical advice from our analysis to moderate this potential effect.

  1. Conclusion

Evaluation of a group of physicians practicing within a single hospi- tal system demonstrated a trend towards a 20% higher admission rates for diagnoses of chest pain, congestive heart failure, asthma, and chronic obstructive pulmonary disease by 20% at a HBED compared to FSEDs. However, this trend did not achieve statistical significance.

Acknowledgements

Justin Schaper, Intermedix, Dallas, Texas.

Nick Lockwood MSIV, Texas College of Osteopathic Medicine, Fort Worth, Texas.

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