Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.
Yale New Haven Hospital-Center for Outcomes Research and Evaluation, New Haven, Connecticut.
JAMA Intern Med. 2019 May 1;179(5):686-693. doi: 10.1001/jamainternmed.2019.0037.
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.
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 = 215 028) 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.
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.
Of the 30 542 691 ED visits to 953 hospitals included in the 2015 National Emergency Department Sample, 215 028 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).
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.
对公立医院的研究报告称，急诊部（ED）无保险患者住院的转移比例不断上升，这被认为与经济激励有关。
在能够提供重症监护的医院中，检查患者保险状况对风险调整后转移和出院率的差异。
设计、地点和参与者：对 2015 年国家急诊部样本进行了横断面分析，包括 2015 年 1 月至 12 月期间的就诊情况。纳入了具有重症监护能力的医院在 2015 年全年（n=215028）因肺炎、慢性阻塞性肺疾病和哮喘这 3 种常见医疗状况进行的成人 ED 就诊。仅纳入了具有先进肺部重症监护能力的医院。
主要结局是患者和医院层面的风险调整 ED 出院、ED 转院和医院入院率。报告了无保险患者、医疗补助和医疗保险受益人和私人保险患者与入院相比出院或转院的调整后几率。医院所有权状况用于二次分析。
在纳入 2015 年国家急诊部样本的 30542691 例 ED 就诊中，有 215028 例（0.7%）是急性肺部疾病，在 160 家有重症监护能力的医院就诊。这些就诊患者的中位（四分位间距 [IQR]）年龄为 55（40-71）岁，主要为女性（124931 [58.1%]）。ED 出院、ED 转院和医院入院率在 ED 之间存在显著差异，未经调整和风险标准化。与私人保险患者相比，无保险患者更有可能出院（优势比 [OR]，1.66；95%CI，1.57-1.76）和转院（调整后的 OR [aOR]，2.41；95%CI，2.08-2.79）。医疗补助受益人的出院几率相当（aOR，1.00；95%CI，0.97-1.04），但转院几率更高（aOR，1.19；95%CI，1.05-1.33）。
在考虑到医院重症监护能力和患者病例组合后，该研究发现，患有常见疾病的无保险患者和医疗补助受益人的医院间转院几率似乎更高。
