Emergency Care at the Crossroads: Emergency Department Crowding, Payment Reform, and One Potential Future

Abstract

In this issue of Annals, Gabayan et al explore the relationship between measures of emergency department (ED) crowding and 2 outcomes: inpatient admission and death. Examining more than 600,000 discharged patients across a dozen EDs in the Kaiser system in California, they found that no ED crowding measures were associated with 7-day mortality, a rare outcome (0.05%). However, 2 of 6 measures of crowding, the evaluation time and ED length of stay, were associated with nearly 4 times higher risk of return and hospital admission with 7 days. To explain the findings, they reasoned that discharged patients evaluated for longer periods had more complex conditions and may be more likely to require later inpatient care. ED crowding alone did not appear to be harmful. Together, this led the authors to cast doubt on the validity of using ED crowding measures as indicators of quality for discharged patients. During the past decade, the ED crowding literature advanced considerably; similarly, but more recently, priorities of US health care policy have evolved rapidly, particularly with the Patient Protection and Affordable Care Act insurance reforms and focus on cost containment. In 2006, the Institute of Medicine released 3 reports that together painted a picture of a broken emergency care system. One report, Hospital-Based Emergency Care: At the Breaking Point, described ED care as crowded, fragmented, and underfunded, bursting at the seams from 2 decades of year-after-year visit increases that outpaced population growth superimposed on shrinking numbers of EDs. Increased volumes were accompanied by greater ED care intensity: more computed tomography use, more laboratory testing, and greater expectations that every test should be completed in the ED before hospital admission. Despite a stream of new sick patients, ED patients destined for admission often sat in a logjam—boarding—awaiting scarce hospital beds. As a result, ED boarders overwhelmed ED resources, causing new sick and injured patients to wait