Study examines hospital compliance with proposed emergency department performance measures

CHICAGO – Compliance with proposed emergency department length of stay measures for admitted, discharged, transferred, and observed patients does not differ significantly between safety-net hospitals (which serve higher proportion of patients with poorer health care status) and non-safety-net hospitals, addressing the issue of whether safety-net hospitals may not be able to meet certain performance measures and could be at risk of reduced funding, according to a study in the February 1 issue of JAMA.

"Pay-for-performance schemes aim to improve quality of care in all arenas of health care, including the emergency department (ED)," according to background information in the article. "One of the main concerns has been the potential for unintended consequences of such measures on facilities that provide care to vulnerable populations. Such consequences are of particular concern to EDs. Although all EDs must, by law, provide care to any patient presenting to their doors, those identified as safety-net EDs provide a disproportionate share of services to patients with Medicaid and the uninsured."

In 2008, the National Quality Forum approved 2 quality measures related to ED length of stay: the median (midpoint) time from arrival to ED departure for admitted patients and for discharged patients. "If these measures are tied to pay for performance, chronically underfunded safety-net EDs could be at risk of further reductions in funding, which could only exacerbate the lack of resources available in those settings."

Christopher Fee, M.D., of the University of California, San Francisco, and colleagues examined the performance of U.S. EDs with respect to length of stay targets of 4 hours for patients discharged to home, transferred to another hospital, or admitted to observation and 8 hours for those admitted to an inpatient bed. The study included ED data from the 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) stratified by hospital safety-net status and patient disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals and 34,134 patient records. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Analyses determined associations with length-of-stay measure compliance.

Of the 2008 NHAMCS data set, 27.9 percent of the weighted visits were excluded for not meeting certain criteria, leaving 72.1 percent for analysis. Of this group, 42.3 percent were seen in safety-net and 57.7 percent in non-safety-net EDs. Overall, patients treated at safety-net EDs were more likely to be young and minority than those treated at non-safety-net EDs. Also, they were less likely to need emergency or urgent care in both admitted and discharged populations.

The researchers found that for admitted patients, the median ED length of stay was 269 minutes for safety-net EDs vs. 281 minutes for non-safety-net EDs. Critical care admissions accounted for 12.5 percent of all admissions to safety-net EDs and 13.2 percent in non-safety-net EDs in 2008. In a comparison between safety-net EDs vs. non-safety-net EDs, the median ED length of stay for critical care admissions was 236 minutes vs. 248 minutes; for discharged patients, the median ED length of stay was 156 minutes vs. 148 minutes; 355 minutes for observations vs. 298 minutes; and 235 minutes for transfers vs. 239 minutes.

"Although concerns have been raised that performance measures, particularly those linked to payment, may ultimately penalize safety-net institutions that are already underfunded and that care for a disproportionate volume of patients with poorer health care status, our findings suggest that those concerns about ED length of stay will not penalize safety-net institutions," the authors write.

(JAMA. 2012;307[5]:476-482. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: This work was supported by a grant from the NIH/NCRR/OD UCSF-CTSI and by the Robert Wood Johnson Foundation Physician Faculty Scholars Program. The authors have completed and submitted the ICMJE form for Disclosure of Potential Conflicts of Interest. Dr. Fee has reported that he received consultancy fees from Google and honoraria from the University of California, San Francisco Office of Continuing Medical Education for organizing and speaking at an annual CME course. Co-author Dr. Burstin is a paid employee of the National Quality Forum. No other disclosures were reported.

In an accompanying editorial, Charles L. Emerman, M.D., of MetroHealth Medical Center, Case Western Reserve University, Cleveland, writes that "quality improvement mandates should be based on evidence that the measures will actually improve patient outcomes."

"Data supporting the notion that overcrowded emergency departments with long boarding times demonstrate some impairment in quality are inconsistent. It is unclear whether mandated reporting of length of stay or other metrics will lead to beneficial changes in patient outcomes. The gist of the available information indicates that meaningful efforts to alleviate emergency department crowding and optimize treatment times will require institutional culture change with a commitment to expediting hospital discharges and providing the necessary resources to ensure that emergency admissions are handled promptly. Relying solely on staff to sponsor change within the walls of the emergency department will be less successful."

(JAMA. 2012;307[5]:511-512. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reports receiving consultancy fees and institutional research grants from Dyax Corp. and fees for giving expert testimony and for lectures related to continuing medical education.

To contact Christopher Fee, M.D., call Elizabeth Fernandez at 415-514-1592 or email efernandez@pubaff.ucsf.edu. To contact editorial author Charles L. Emerman, M.D., call Christina Karas at 216-778-5370 or email ckaras@metrohealth.org.