The Growing Role of Emergency Departments in Hospital Admissions

Sat Aug 11 20:45:57 PDT 2012

August 2, 2012

The Growing Role of Emergency Departments in Hospital Admissions

New England Journal of Medicine

By Jeremiah D. Schuur, M.D., M.H.S., and Arjun K. Venkatesh, M.D., M.B.A.

Growing use of U.S. emergency departments (EDs), cited as a key contributor to rising health care costs, has become a leading target of health care reform. ED visit rates increased by more than a third between 1997 and 2007, and EDs are increasingly the safety net for underserved patients, particularly adult Medicaid beneficiaries. Although much attention has been paid to increasing ED use, the ED's changing role in our health care system has been less thoroughly examined. EDs serve as a hub for prehospital emergency medical systems, an acute diagnostic and treatment center, a primary safety net, and a 24/7 portal for rapid inpatient admission. Approximately a quarter of all acute care outpatient visits in the United States occur in EDs, a proportion that has been growing since 2001. We examined the proportion of hospital admissions that come through the ED, hypothesizing that use of the ED as the admission portal had increased across conditions.

We analyzed data from the Nationwide Inpatient Sample (NIS), the largest all-payer database of U.S. inpatient care, from 1993 to 2006 (the most recent year for which the ED admission data are available on HCUPnet, an interactive Web-based tool that uses data from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality). The NIS contains data from approximately 8 million hospital stays each year and is weighted to produce national estimates. We used HCUPnet to query the NIS regarding trends in the 20 clinical conditions for which patients were most frequently admitted to the hospital in 2006. Clinical Classifications Software was used to group the conditions into clinically meaningful categories. We excluded two conditions for which patients are rarely admitted through the ED (osteoarthritis and back problems), one psychiatric condition that was not consistently coded in claims data (affective disorder), and four obstetrical diagnoses that are generally evaluated in other care settings, such as labor-and-delivery triage areas (liveborn infant, maternal birth trauma, other complications of birth, other complications of pregnancy).

The number of hospital admissions increased by 15.0%, from 34.3 million in 1993 to 39.5 million in 2006; admissions from the ED increased by 50.4%, from 11.5 million to 17.3 million. The proportion of all inpatient stays involving admission from the ED increased from 33.5 to 43.8% (P<0.001). In 12 of the 13 conditions for which patients were most frequently admitted and that met our inclusion criteria, an increased proportion of admitted patients came through the ED (P<0.001), regardless of the trend in overall admissions; the exception was coronary atherosclerosis, for which rapid “rule-out” protocols and ED-based chest-pain observation units have reduced the need for inpatient admission. (For details on the 12 conditions, see the Supplementary Appendix, available with the full text of this article at NEJM.org.) 

Historically, clinically stable patients with acute problems who required hospital care for conditions such as community-acquired pneumonia would see an outpatient provider and be directly admitted from the physician's office. Our findings show that since 1993, EDs have played an increasing role in admissions for almost all conditions.

There are several possible explanations of this growing role. One frequently cited hypothesis is that overuse of the ED for conditions that would more appropriately be treated in primary care providers' offices could lead to increased admission rates — either because reduced access to primary care leads to worsening of patients' conditions and greater need for emergency hospitalization or because emergency physicians are more likely than primary care providers to admit patients to the hospital. The latter theory is based in part on assumptions that emergency physicians are trained to assume the worst and are more likely to admit patients with uncertain diagnoses and with whom they don't have an ongoing relationship, and that they are unwilling to discharge patients when they cannot guarantee outpatient follow-up.

Alternatively, the trend could be driven by changes in the organization of medical services that favor the rapid diagnostic technologies and early treatment available in the ED. As diagnostic services have improved (with the introduction of such tools as computed tomographic scanning and troponin testing) and expectations of rapid and accurate diagnosis and treatment have become standard (e.g., percutaneous coronary intervention for ST-segment–elevation myocardial infarction), the evaluation of common symptoms such as chest pain, abdominal pain, and shortness of breath has become de facto reasons for ED referral. Public education campaigns emphasizing the importance of early emergency care for symptoms suggestive of heart attack or stroke have encouraged this approach.

In addition, primary care providers are less likely than EDs to provide regular access for unscheduled acute care — and therefore less likely to admit patients to the hospital. A large national survey and observational studies have found that it is difficult for patients to arrange a sick visit with a primary care provider in a timely fashion, because schedules are often full, after-hours service is unavailable, and many acute problems are not well suited to office practices lacking basic laboratory and imaging capabilities. As hospitals strive for administrative efficiency by maximizing occupancy rates, it becomes more difficult for outpatient providers to admit patients directly to the hospital. Yet since such hospitals' practices have largely been reactive, it is unclear whether this trend reflects high-value use of limited emergency care resources and whether it has resulted in more or less appropriate use of scarce inpatient beds.

This increasing use of EDs for inpatient admissions has important implications for the redesign of delivery systems. The need for more efficient use of inpatient resources is a clear focus of the Affordable Care Act (ACA), and the increased role of EDs in inpatient admissions will affect the implementation of central ACA principles, such as quality measurement, care coordination, and payment reform. Yet policymakers seem to view EDs as little more than a locus of inefficient or unnecessary care — the place where patients without access or insurance seek care at great expense to taxpayers. This popular view fails to address the ED's increasingly important role in hospital admissions, and it is not supported by the data.

EDs' growing role in hospital admissions is a clue to their critical role in the health care system. Rigorous research to identify drivers of this trend and determine the value or cost of emergency care is needed to inform health policy. For example, comparative effectiveness studies on admission from the ED versus direct admission can evaluate whether early access to diagnostic and therapeutic services improves outcomes while shortening lengths of stay. Similarly, studies of conditions that are ideally evaluated in the ED, such as chest pain, must demonstrate the ability of evidence-based rapid diagnostic pathways to safely stratify patients according to risk level and reduce admissions rates.

Should we return to having primary care providers initiate and direct hospital admissions? Because of the increasingly specialized nature of patient care, our systems have evolved into separate arenas of hospital-based and ambulatory care provided by clinicians with different types of training. As reimbursement models shift from providing incentives for admissions as a hospital's revenue source to providing incentives for reducing admissions, EDs will probably reduce their use of hospital admission. Yet the ACA's expansion of insurance coverage, the reality of an aging population with complex conditions, and the expectation of timely, specialized, and coordinated care mean that the trend toward increasing percentages of ED admissions is unlikely to be reversed. New models of acute care delivery aiming to improve the use of scarce intensive, hospital-based services should take into account this change in patient and provider expectations.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article was published on July 11, 2012, at NEJM.org.

From the Department of Emergency Medicine, Brigham and Women's Hospital (J.D.S.); the Brigham and Women's Hospital–Massachusetts General Hospital–Harvard Affiliated Emergency Medicine Residency Program (A.K.V.); and the Department of Medicine, Harvard Medical School (J.D.S., A.K.V.) — all in Boston.

Bryan Sloane
Deputy Editor, CAL/AAEM News Service

Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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