Going with the Flow: Left Without Being Seen in the Emergency Department

Background: Emergency Department (ED) crowding negatively impacts patient care. Delays in receiving care increases the probability that some patients will leave without being seen (LWBS) by a medical provider. The scope and significance of LWBS has prompted the Centers for Medicare and Medicaid to monitor LWBS and to reimburse hospitals based on LWBS rates. However, there is no plan to consider patient case mix or organizational characteristics in the LWBS reimbursement program. The new reimbursement policy may unfairly burden organizations providing care to vulnerable populations. Objectives: The objectives of this study were to: verify the association between patient characteristics and LWBS found in previous studies; determine if there is an association between organizational characteristics and LWBS and explore how organizational characteristics may moderate the relationship between patient characteristics and LWBS. Methods: A secondary analysis of national ED data from 2007-2010 was performed. Multilevel models were constructed to explain variance in the outcome variable, LWBS, at the patient and organizational level. Level-1 slope coefficients were tested as random effects and coefficients with significant random effects were included in cross-level interactions to explain the random slope variability. Results: This study verified the association between patient characteristics and LWBS found in previous studies. The following were associated with higher LWBS rates in: younger patients, lower acuity (acuity 4 and 5), arriving after 11 a.m., and Black Non-Hispanic Race/ethnicity. This study also found an association between organizational characteristics and LWBS. There was variation in LWBS across hospitals, with higher LWBS rates in metropolitan and Southern EDs. Organizational characteristics were found to moderate the relationship between patient characteristics and LWBS, with significant cross-level interactions for the following: Metropolitan Statistical Area (MSA) and arrival, ownership and race/ethnicity, and region and race/ethnicity. Conclusions: The results of this study have several implications. Regarding policy, to avoid unfairly penalizing hospitals providing a significant amount of care to vulnerable populations, top performers within MSA status and region should be established for reimbursement purposes. To improve patient flow, hospitals need match capacity with demand by establishing fast tracks dedicated to low acuity patients and implementing vertical patient flow for acuity 3 patients.Doctor of Philosoph