Racial and ethnic disparities in hospital observation in Maryland

Cody Cichowitz, Gideon Loevinsohn, Eili Y. Klein, Elizabeth Colantuoni, Panagis Galiatsatos, Jodi Rennert, Nathan A. Irvin

Research output: Contribution to journalArticlepeer-review


Objectives: Hospital observation is a key disposition option from the emergency department (ED) and encompasses up to one third of patients requiring post-ED care. Observation has been associated with higher incidence of catastrophic financial costs and has downstream effects on post-discharge clinical services. Yet little is known about the non-clinical determinants of observation assignment. We sought to evaluate the impact of patient-level demographic factors on observation designation among Maryland patients. Methods: We conducted a retrospective analysis of all ED encounters in Maryland between July 2012 and January 2017 for four priority diagnoses (heart failure, chronic obstructive pulmonary disease [COPD], pneumonia, and acute chest pain) using multilevel logistic models allowing for heterogeneity of the effects across hospitals. The primary exposure was self-reported race and ethnicity. The primary outcome was the initial status assignment from the ED: hospital observation versus inpatient admission. Results: Across 46 Maryland hospitals, 259,788 patient encounters resulted in a disposition of inpatient admission (65%) or observation designation (35%). Black (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 1.16–1.23) and Hispanic (aOR: 1.11; 95% CI: 1.01–1.21) patients were significantly more likely to be placed in observation than white, non-Hispanic patients. These differences were consistent across the majority of acute-care hospitals in Maryland (27/46). Conclusion: Black and Hispanic patients in Maryland are more likely to be treated under the observation designation than white, non-Hispanic patients independent of clinical presentation. Race agnostic, time-based status assignments may be key in eliminating these disparities.

Original languageEnglish (US)
Pages (from-to)532-538
Number of pages7
JournalAmerican Journal of Emergency Medicine
StatePublished - Aug 2021


  • Disparities
  • Equity
  • Hospital observation
  • Patient disposition

ASJC Scopus subject areas

  • Emergency Medicine


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