Compliance with proposed ED length-of-stay measures for admitted, discharged, transferred and observed patients does not differ significantly between safety-net hospitals — those that provide significant levels of care to low-income, uninsured and vulnerable populations — and non-safety-net hospitals, according to a study.

The finding may address concerns that safety-net hospitals could be at risk of reduced funding by failing to meet certain performance measures.

"Pay-for-performance schemes aim to improve quality of care in all arenas of healthcare, including the ED," the authors wrote in background information in the study, which appears in the Feb. 1 issue of JAMA. "One of the main concerns has been the potential for unintended consequences of such measures on facilities that provide care to vulnerable populations.

"Such consequences are of particular concerns to EDs. Although all EDs must, by law, provide care to any patient presenting to their doors, those identified as safety-net EDs provide a disproportionate share of services to patients with Medicaid and the uninsured."

In 2008, the National Quality Forum approved two quality measures related to ED length of stay: the median (midpoint) times from arrival to ED departure for admitted patients and for discharged patients. "If these measures are tied to pay-for-performance, chronically underfunded safety-net EDs could be at risk of further reductions in funding, which could only exacerbate the lack of resources available in those settings."

Christopher Fee, MD, of the University of California, San Francisco, and colleagues examined the performance of U.S. EDs with respect to length of stay targets of four hours for patients discharged to home, transferred to another hospital or admitted to observation, and eight hours for those admitted to an inpatient bed. The study included ED data from the 2008 National Hospital Ambulatory Medical Care Survey stratified by hospital safety-net status and patient disposition (admission, discharge, observation, transfer).

Of the 2008 NHAMCS data set, 72.1% of the weighted visits met the criteria for analysis. Of this group, 42.3% were seen in safety-net and 57.7% in non-safety-net EDs. Overall, patients treated at safety-net EDs were more likely to be young and minority than those treated at non-safety-net EDs. Also, they were less likely to need emergency or urgent care in both admitted and discharged populations.

The researchers found that for admitted patients, the median ED length of stay was 269 minutes for safety-net EDs vs. 281 minutes for non-safety-net EDs. Critical care admissions accounted for 12.5% of all admissions to safety-net EDs and 13.2% in non-safety-net EDs in 2008. In a comparison between safety-net EDs vs. non-safety-net EDs, the median ED length of stay for critical care admissions was 236 minutes vs. 248 minutes.

For discharged patients, the median ED length of stay was 156 minutes vs. 148 minutes; 355 minutes for observations vs. 298 minutes; and 235 minutes for transfers vs. 239 minutes.

"Although concerns have been raised that performance measures, particularly those linked to payment, may ultimately penalize safety-net institutions that are already underfunded and that care for a disproportionate volume of patients with poorer healthcare status, our findings suggest that those concerns about ED length of stay will not penalize safety-net institutions."

To read a study summary and access the study via subscription or purchase, visit http://bit.ly/y1wWgM.