TY - JOUR
T1 - Association between Insurance Status and Access to Hospital Care in Emergency Department Disposition
AU - Venkatesh, Arjun K.
AU - Chou, Shih Chuan
AU - Li, Shu Xia
AU - Choi, Jennie
AU - Ross, Joseph S.
AU - D'Onofrio, Gail
AU - Krumholz, Harlan M.
AU - Dharmarajan, Kumar
N1 - Funding Information:
part by an Emergency Medicine Foundation Health Policy Scholar Award and a Yale Center for Clinical Investigation grant KL2 TR000140 from the National Center for Advancing Translational Science of the NIH (Dr Venkatesh), by a Paul B. Beeson Career Development Award grant K23AG048331 from the National Institute on Aging and the American Federation for Aging Research, and a Yale Claude D. Pepper Older Americans Independence Center grant P30AG021342 (Dr Dharmarajan).
Publisher Copyright:
© 2019 American Medical Association. All rights reserved.
PY - 2019/5
Y1 - 2019/5
N2 - Importance: Studies of public hospitals have reported increasing incidence of emergency department (ED) transfers of uninsured patients for hospitalization, which is perceived to be associated with financial incentives. Objective: To examine the differences in risk-adjusted transfer and discharge rates by patient insurance status among hospitals capable of providing critical care. Design, Setting, and Participants: A cross-sectional analysis of the 2015 National Emergency Department Sample was conducted, including visits between January 2015 and December 2015. Adult ED visits throughout 2015 (n = 215028) for the 3 common medical conditions of pneumonia, chronic obstructive pulmonary disease, and asthma, at hospitals with intensive care capabilities were included. Only hospitals with advanced critical care capabilities for pulmonary care were included. Main Outcomes and Measures: The primary outcomes were patient-level and hospital-level risk-adjusted ED discharges, ED transfers, and hospital admissions. Adjusted odds of discharge or transfer compared with admission among uninsured patients, Medicaid and Medicare beneficiaries, and privately insured patients are reported. Hospital ownership status was used for the secondary analysis. Results: Of the 30542691 ED visits to 953 hospitals included in the 2015 National Emergency Department Sample, 215028 visits (0.7%) were for acute pulmonary diseases to 160 intensive care-capable hospitals. These visits were made by patients with a median (interquartile range [IQR]) age of 55 (40-71) years and who were predominantly female (124 931 [58.1%]). Substantial variation in unadjusted and risk-standardized ED discharge, ED transfer, and hospital admission rates was found across EDs. Compared with privately insured patients, uninsured patients were more likely to be discharged (odds ratio [OR], 1.66; 95% CI, 1.57-1.76) and transferred (adjusted OR [aOR], 2.41; 95% CI, 2.08-2.79). Medicaid beneficiaries had comparable odds of discharge (aOR, 1.00; 95% CI, 0.97-1.04) but higher odds of transfer (aOR, 1.19; 95% CI, 1.05-1.33). Conclusions and Relevance: After accounting for hospital critical care capability and patient case mix, the study found that uninsured patients and Medicaid beneficiaries with common medical conditions appeared to have higher odds of interhospital transfer.
AB - Importance: Studies of public hospitals have reported increasing incidence of emergency department (ED) transfers of uninsured patients for hospitalization, which is perceived to be associated with financial incentives. Objective: To examine the differences in risk-adjusted transfer and discharge rates by patient insurance status among hospitals capable of providing critical care. Design, Setting, and Participants: A cross-sectional analysis of the 2015 National Emergency Department Sample was conducted, including visits between January 2015 and December 2015. Adult ED visits throughout 2015 (n = 215028) for the 3 common medical conditions of pneumonia, chronic obstructive pulmonary disease, and asthma, at hospitals with intensive care capabilities were included. Only hospitals with advanced critical care capabilities for pulmonary care were included. Main Outcomes and Measures: The primary outcomes were patient-level and hospital-level risk-adjusted ED discharges, ED transfers, and hospital admissions. Adjusted odds of discharge or transfer compared with admission among uninsured patients, Medicaid and Medicare beneficiaries, and privately insured patients are reported. Hospital ownership status was used for the secondary analysis. Results: Of the 30542691 ED visits to 953 hospitals included in the 2015 National Emergency Department Sample, 215028 visits (0.7%) were for acute pulmonary diseases to 160 intensive care-capable hospitals. These visits were made by patients with a median (interquartile range [IQR]) age of 55 (40-71) years and who were predominantly female (124 931 [58.1%]). Substantial variation in unadjusted and risk-standardized ED discharge, ED transfer, and hospital admission rates was found across EDs. Compared with privately insured patients, uninsured patients were more likely to be discharged (odds ratio [OR], 1.66; 95% CI, 1.57-1.76) and transferred (adjusted OR [aOR], 2.41; 95% CI, 2.08-2.79). Medicaid beneficiaries had comparable odds of discharge (aOR, 1.00; 95% CI, 0.97-1.04) but higher odds of transfer (aOR, 1.19; 95% CI, 1.05-1.33). Conclusions and Relevance: After accounting for hospital critical care capability and patient case mix, the study found that uninsured patients and Medicaid beneficiaries with common medical conditions appeared to have higher odds of interhospital transfer.
UR - http://www.scopus.com/inward/record.url?scp=85063677306&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85063677306&partnerID=8YFLogxK
U2 - 10.1001/jamainternmed.2019.0037
DO - 10.1001/jamainternmed.2019.0037
M3 - Article
C2 - 30933243
AN - SCOPUS:85063677306
SN - 2168-6106
VL - 179
SP - 686
EP - 693
JO - JAMA internal medicine
JF - JAMA internal medicine
IS - 5
ER -