Abstract
Background
Emergency Department (ED) boarding, the practice of holding patients in the ED after
they have been admitted to the hospital due to unavailability of inpatient beds, is
common and contributes to the public health crisis of ED crowding. Prior work has
documented the harms of ED boarding on access and quality of care. Limited studies
examine the relationship between ED boarding and an equally important domain of quality—the
cost of care. This study evaluates the relationship between ED boarding, ED characteristics
and risk-adjusted hospitalization costs utilizing national publicly-reported measures.
Methods
We conducted a cross-sectional analysis of two 2018 Centers for Medicare and Medicaid
Services (CMS) Hospital Compare datasets: 1) Medicare Hospital Spending per Patient
and 2) Timely and Effective Care. We constructed a hospital-level multivariate linear
regression analysis to examine the association between ED boarding and Medicare spending
per beneficiary (MSPB), adjusting for ED length of stay, door to diagnostic evaluation
time, and ED patient volume.
Results
A total of 2903 hospitals were included in the analysis. ED boarding was significantly
correlated with MSPB (r = 0.1774; p-value: < 0.0001). In multivariate regression, ED boarding was also positively associated
with MSPB (Beta: 0.00015; p < 0.0001) after adjustment for other hospital level crowding indicators.
Conclusion
We found a strong relationship between measures of ED crowding, including ED boarding,
and risk-adjusted hospital spending. Future work should elucidate the mediators of
this relationship. Policymakers and administrators should consider the financial harms
of ED boarding when devising strategies to improve hospital care access and flow.
Keywords
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References
- Emergency department throughput, crowding, and financial outcomes for hospitals.Acad Emerg Med. 2010; 17 ([published Online First: 2010/07/31]): 840-847https://doi.org/10.1111/j.1553-2712.2010.00814.x
- IOM report: the future of emergency care in the United States health system.Acad Emerg Med. 2006; 13 ([published Online First: 2006/10/04]): 1081-1085https://doi.org/10.1197/j.aem.2006.07.011
- Hospital-Based Emergency Care: At the Breaking Point.The National Academies Press, Washington, DC2007
- The opportunity loss of boarding admitted patients in the emergency department.Acad Emerg Med. 2007; 14 ([published Online First: 2007/03/03]): 332-337https://doi.org/10.1197/j.aem.2006.11.011
- Policy Statement: Definition of Boarded Patient.American College of Emergency Physicians, 2018 (Available from)
- The effect of emergency department crowding on clinically oriented outcomes.Acad Emerg Med. 2009; 16 ([published Online First: 2008/11/15]): 1-10https://doi.org/10.1111/j.1553-2712.2008.00295.x
- The effect of emergency department crowding on patient satisfaction for admitted patients.Acad Emerg Med. 2008; 15 ([published Online First: 2009/02/27]): 825-831https://doi.org/10.1111/j.1553-2712.2008.00200.x
- Working in an overcrowded accident and emergency department: nurses’ narratives.Aust J Adv Nurs. 2007; 25: 21-27
- Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction.J Healthc Manag. 2005; 50: 327-340
- Effect of Boarding on Mortality in ICUs.Crit Care Med. 2018; 46 ([published Online First: 2017/12/19]): 525-531https://doi.org/10.1097/CCM.0000000000002905
- The association between length of emergency department boarding and mortality.Acad Emerg Med. 2011; 18 ([published Online First: 2011/12/16]): 1324-1329https://doi.org/10.1111/j.1553-2712.2011.01236.x
- The impact of ED crowding on early interventions and mortality in patients with severe sepsis.Am J Emerg Med. 2017; 35 ([published Online First: 2017/02/25]): 953-960https://doi.org/10.1016/j.ajem.2017.01.061
- Emergency department crowding, part 1--concept, causes, and moral consequences.Ann Emerg Med. 2009; 53 ([published Online First: 2008/11/26]): 605-611https://doi.org/10.1016/j.annemergmed.2008.09.019
- Effect of emergency department crowding on outcomes of admitted patients.Ann Emerg Med. 2013; 61 ([published Online First: 2012/12/12]): 605-11e6https://doi.org/10.1016/j.annemergmed.2012.10.026
- Crisis in the emergency department.N Engl J Med. 2006; 355 ([published Online First: 2006/09/29]): 1300-1303https://doi.org/10.1056/NEJMp068194
- A cross-sectional study of emergency department boarding practices in the United States.Acad Emerg Med. 2014; 21 ([published Online First: 2014/05/21]): 497-503https://doi.org/10.1111/acem.12375
- The impact of delays to admission from the emergency department on inpatient outcomes.BMC Emerg Med. 2010; 10 ([published Online First: 2010/07/14]): 16https://doi.org/10.1186/1471-227X-10-16
- Financial impact of emergency department crowding.West J Emerg Med. 2011; 12 ([published Online First: 2011/06/22]): 192-197
Centers for Medicare and Medicaid Services. Hospital Compare [Available from: https://www.medicare.gov/hospitalcompare/search.html? (accessed July 1, 2017) 2017.
- Standardizing medicare payment information to support examining geographic variation in costs.Medicare Medicaid Res Rev. 2013; 3 ([published Online First: 2013/01/01])https://doi.org/10.5600/mmrr.003.03.a06
- Medicare Spending Per Beneficiary (MSPB) Measure Methodology.(Available from:)
- Managing and measuring emergency department care: results of the fourth emergency department benchmarking definitions summit.Acad Emerg Med. 2020; 27 ([published Online First: 2020/04/06]): 600-611https://doi.org/10.1111/acem.13978
- Approved: standards revisions addressing patient flow through the emergency department.Jt Comm Perspect. 2012; 32 (3–5. [published Online First: 2012/09/14]): 1
- Solutions to emergency department ‘boarding’ and crowding are underused and may need to be legislated.Health Aff (Millwood). 2012; 31 ([published Online First: 2012/08/08]): 1757-1766https://doi.org/10.1377/hlthaff.2011.0786
- The boarding experience from the patient perspective: the wait.Emerg Med J. 2015; 32: 854https://doi.org/10.1136/emermed-2014-204107
- Emergency department length of stay independently predicts excess inpatient length of stay.Med J Australia. 2003; 179: 524-526https://doi.org/10.5694/j.1326-5377.2003.tb05676.x
- Increased health-care costs associated with Ed overcrowding.Am J Emerg Med. 1994; 12: 265-266https://doi.org/10.1016/0735-6757(94)90135-X
- Emergency department rapid medical assessment: overall effect and mechanistic considerations.J Emerg Med. 2015; 48: 620-627https://doi.org/10.1016/j.jemermed.2014.12.025
Article Info
Publication History
Published online: November 13, 2020
Accepted:
October 29,
2020
Received in revised form:
September 29,
2020
Received:
August 17,
2020
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
