Association between Insurance Status and Access to Hospital Care in Emergency Department Disposition

Arjun K. Venkatesh, Shih Chuan Chou, Shu Xia Li, Jennie Choe, Joseph S. Ross, Gail D'Onofrio, Harlan M. Krumholz, Kumar Dharmarajan

Research output: Contribution to journalArticle

Abstract

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.

Original languageEnglish (US)
Pages (from-to)686-693
Number of pages8
JournalJAMA internal medicine
Volume179
Issue number5
DOIs
StatePublished - May 1 2019
Externally publishedYes

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Insurance Coverage
Hospital Emergency Service
Critical Care
Medicaid
Odds Ratio
Patient Transfer
Patient Discharge
Ownership
Diagnosis-Related Groups
Public Hospitals
Acute Disease
Medicare
Chronic Obstructive Pulmonary Disease
Lung Diseases
Motivation
Pneumonia
Hospitalization
Asthma
Cross-Sectional Studies
Outcome Assessment (Health Care)

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Venkatesh, A. K., Chou, S. C., Li, S. X., Choe, J., Ross, J. S., D'Onofrio, G., ... Dharmarajan, K. (2019). Association between Insurance Status and Access to Hospital Care in Emergency Department Disposition. JAMA internal medicine, 179(5), 686-693. https://doi.org/10.1001/jamainternmed.2019.0037

Association between Insurance Status and Access to Hospital Care in Emergency Department Disposition. / Venkatesh, Arjun K.; Chou, Shih Chuan; Li, Shu Xia; Choe, Jennie; Ross, Joseph S.; D'Onofrio, Gail; Krumholz, Harlan M.; Dharmarajan, Kumar.

In: JAMA internal medicine, Vol. 179, No. 5, 01.05.2019, p. 686-693.

Research output: Contribution to journalArticle

Venkatesh, AK, Chou, SC, Li, SX, Choe, J, Ross, JS, D'Onofrio, G, Krumholz, HM & Dharmarajan, K 2019, 'Association between Insurance Status and Access to Hospital Care in Emergency Department Disposition', JAMA internal medicine, vol. 179, no. 5, pp. 686-693. https://doi.org/10.1001/jamainternmed.2019.0037
Venkatesh, Arjun K. ; Chou, Shih Chuan ; Li, Shu Xia ; Choe, Jennie ; Ross, Joseph S. ; D'Onofrio, Gail ; Krumholz, Harlan M. ; Dharmarajan, Kumar. / Association between Insurance Status and Access to Hospital Care in Emergency Department Disposition. In: JAMA internal medicine. 2019 ; Vol. 179, No. 5. pp. 686-693.
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abstract = "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.",
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