The emergency department as a pathway to admission for poor and high-cost patients

--To determine the importance of the emergency department as the means of access to the hospital for the poor and the fiscal implications of providing these services, we examined the relationship between patients' socioeconomic status and admission via the emergency department. We also determined the association between entering the hospital via the emergency department and hospital resource use.

--We conducted a study of 20,089 patients admitted to five Massachusetts hospitals (three community, two tertiary care) during a 6-month period. We determined the proportions of patients within various socioeconomic and disease groupings who entered through the emergency department. We compared length of stay and charges for patients admitted through the emergency department with those for patients admitted through other routes.

--Overall, 51% of patients entered via the emergency department. Elderly patients (age greater than 65 years; odds ratio, 1.87) and patients with lower socioeconomic status as measured by income, occupation, and education (odds ratios, 2.38, 1.47, and 1.69, respectively) were more likely to enter the hospital via the emergency department than other patients. After adjustment for diagnosis related group, severity as measured by DRGSCALE, and socioeconomic status as measured by income, and excluding outliers, patients admitted via the emergency department stayed 27% longer and incurred 13% higher charges than other patients (P less than .001).

--Our data indicate that patients with lower socioeconomic status are more likely than other patients to use the emergency department as their means of access to the hospital and that patients admitted via the emergency department use far more resources than patients in the same diagnosis related group admitted by other means. Hospitals that make emergency department services more available may be more likely to hospitalize socioeconomically disadvantaged patients and may be at a substantial financial disadvantage under per-case reimbursement systems such as Medicare.