Do Financial Incentives Change Length-of-stay Performance in Emergency Departments? A Retrospective Study of the Pay-for-performance Program in Metro Vancouver

Acad Emerg Med. 2019 Aug;26(8):856-866. doi: 10.1111/acem.13635. Epub 2019 Jul 18.


Background: Pay-for-performance (P4P) programs have been implemented in various forms to reduce emergency department (ED) patient length of stay (LOS). This retrospective study investigated to what extent the timing of patient disposition in Metro Vancouver EDs was influenced by a LOS-based P4P program.

Methods: We analyzed ED visit records of four major hospitals in Metro Vancouver, Canada. For each ED, we individually tested whether LOS was distributed discontinuously at the LOS target before and after the P4P program was terminated. For the P4P effective period, we examined whether patients discharged just prior to the LOS target had a higher 7-day return-and-admission (RA) rate-the probability that a patient, after being discharged home, returned to any ED within 7 days and was admitted to an inpatient unit-than patients discharged just after the target.

Results: Prior to the termination of the P4P program, in all four EDs, the LOS density of admitted patients was discontinuous and had a significant drop at the P4P 10-hours admission LOS target; a similar phenomenon was observed among discharged patients at the 4-hours discharge LOS target, but only in the two lower-volume EDs. Furthermore, in a lower-volume ED, patients who were discharged right before the 4-hours P4P LOS target had a higher 7-day RA rate than patients discharged right after the LOS target. After the termination of the discharge incentive, the discontinuity at the discharge LOS target became less evident, but patients were still more frequently admitted just before 10 hours in three of the four EDs as the local health authority continued to support the admission incentive scheme after the government terminated the P4P program.

Conclusions: The LOS-based financial incentive scheme appears to have influenced the timing of ED patient dispositions. The results suggest mixed consequences of the P4P program-it can reduce access block for admitted patients but may also lead to discharges associated with return visits and admissions.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • British Columbia
  • Emergency Service, Hospital / economics*
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Humans
  • Length of Stay / economics
  • Length of Stay / statistics & numerical data*
  • Male
  • Middle Aged
  • Patient Discharge / economics
  • Patient Discharge / statistics & numerical data*
  • Reimbursement, Incentive / economics*
  • Retrospective Studies