Objectives: Recent studies have demonstrated the adverse effects of prolonged emergency department (ED) boarding times on outcomes. The authors sought to examine racial disparities across U.S. hospitals in ED length of stay (LOS) for admitted patients, which may serve as a proxy for boarding time in data sets where the actual time of admission is unavailable. Specifically, the study estimated both the within- and among-hospital effects of black versus non-black race on LOS for admitted patients.
Methods: The authors studied 14,516 intensive care unit (ICU) and non-ICU admissions in 408 EDs in the National Hospital Ambulatory Medical Care Survey (NHAMCS; 2003-2005). The main outcomes were ED LOS (triage to transfer to inpatient bed) and proportion of patients with prolonged LOS (>6 hours). The effects of black versus non-black race on LOS were decomposed to distinguish racial disparities between patients at the same hospital (within-hospital component) and between hospitals that serve higher proportions of black patients (among-hospital component).
Results: In the unadjusted analyses, ED LOS was significantly longer for black patients admitted to ICU beds (367 minutes vs. 290 minutes) and non-ICU beds (397 minutes vs. 345 minutes). For admissions to ICU beds, the within-hospital estimates suggested that blacks were at higher risk for ED LOS of >6 hours (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.01 to 2.01), while the among-hospital differences were not significant (OR = 1.08 for each 10% increase in the proportion of black patients, 95% CI = 0.96 to 1.23). By contrast, for non-ICU admissions, the within-hospital racial disparities were not significant (OR = 1.12, 95% CI = 0.94 to 1.23), but the among-hospital differences were significant (OR = 1.13, 95% CI = 1.04 to 1.22) per 10% point increase in the percentage of blacks admitted to a hospital.
Conclusions: Black patients who are admitted to the hospital through the ED have longer ED LOS compared to non-blacks, indicating that racial disparities may exist across U.S. hospitals. The disparity for non-ICU patients might be accounted for by among-hospital differences, where hospitals with a higher proportion of blacks have longer waits. The disparity for ICU patients is better explained by within-hospital differences, where blacks have longer wait times than non-blacks in the same hospital. However, there may be additional unmeasured clinical or socioeconomic factors that explain these results.