Stern R S, Weissman J S, Epstein A M
Department of Dermatology, Beth Israel Hospital, Harvard Medical School, Boston, MA 02215.
JAMA. 1991;266(16):2238-43.
--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.
为了确定急诊科作为贫困人口进入医院的途径的重要性以及提供这些服务的财政影响，我们研究了患者社会经济地位与通过急诊科入院之间的关系。我们还确定了通过急诊科入院与医院资源使用之间的关联。
我们对6个月期间在马萨诸塞州五家医院（三家社区医院、两家三级护理医院）住院的20089名患者进行了研究。我们确定了不同社会经济和疾病分组中通过急诊科入院的患者比例。我们比较了通过急诊科入院的患者与通过其他途径入院的患者的住院时间和费用。
总体而言，51%的患者通过急诊科入院。老年患者（年龄大于65岁；优势比为1.87）以及按收入、职业和教育衡量社会经济地位较低的患者（优势比分别为2.38、1.47和1.69）比其他患者更有可能通过急诊科入院。在对诊断相关组、按DRGSCALE衡量的病情严重程度以及按收入衡量的社会经济地位进行调整后，排除异常值，通过急诊科入院的患者比其他患者住院时间长27%，费用高13%（P<0.001）。
我们的数据表明，社会经济地位较低的患者比其他患者更有可能将急诊科作为进入医院的途径，并且通过急诊科入院的患者比通过其他方式入院的同诊断相关组患者使用的资源要多得多。使急诊科服务更容易获得的医院可能更有可能收治社会经济弱势患者，并且在诸如医疗保险等按病例报销系统下可能面临巨大的财务劣势。
