Published data demonstrate that hospitalizations represent a significant portion of the annual expenditures for the United States healthcare system. A recent analysis by the RAND Corporation showed that emergency physicians are playing a greater role in healthcare beyond the services they provide in the ED. “Gaining a better understanding of recent changes in the sources of unscheduled ED admissions may provide opportunities to improve the quality and cost of inpatient care,” says Keith E. Kocher, MD, MPH.

Analyzing the Effects

In the journal Medical Care, Dr. Kocher and colleagues published an observational study examining the sources of unscheduled hospitalization over a 10-year period using data from the Nationwide Inpatient Sample. They also assessed implications for inpatient mortality and length of stay. Unscheduled hospitalizations were categorized as those related to transfers, direct admissions from outpatient providers, and the ED.

Study results showed that about 82% of unscheduled admissions to the hospital came through the ED in 2009, representing a sharp increase from the 65% rate that was observed in 2000. Unscheduled hospitalizations arising from direct admissions and the ED changed substantially, while those due to transfers remained relatively stable. Direct admissions from clinics or doctors’ offices declined from about 31% to 14% of unscheduled admissions.


Lower Mortality, Shorter Stays

“In 2009, hospitalizations through the ED were associated with lower mortality overall when compared with direct admissions,” says Dr. Kocher. “These hospitalizations were also associated with a shorter hospital length of stay. These findings occurred despite a higher severity illness among patients and a greater chronic disease burden in 2009. It’s remarkable that patients admitted to the hospital from the ED were generally sicker but still had lower mortality and shorter hospital stays.”

Sources of unscheduled hospitalizations in the U.S. have evolved, mostly from care now originating in the ED, adds Dr. Kocher. “The ED was the source of admission for a wide variety of clinical conditions, including medical and surgical disease as well as mental illness. It was also the source of admission for more vulnerable patient groups, such as the elderly, minorities, and the uninsured. Fortunately, this trend doesn’t seem to be harming patients or worsening length of stay.”

“Hospitalizations through the ED were associated with lower mortality overall when compared with direct admissions.”

Examining the Implications

The study by Dr. Kocher and colleagues, when viewed collectively with data from the recent RAND Corporation study, demonstrates that the ED has become the major portal for unscheduled hospitalizations in the U.S. “It’s important for administrators and policy makers to focus their attention on physicians and caregivers in the ED. These providers are increasingly making the decisions to admit patients. Acute care management is continuing to evolve away from primary care providers. This trend has the potential to exacerbate our already fragmented healthcare system.”


Kocher KE, Dimick JB, Nallamothu BK. Changes in the source of unscheduled hospitalizations in the United States. Med Care. 2013;51:689-698. Available at:

Kocher KE, Nallamothu BK, Birkmeyer JD, Dimick JB. Emergency department visits after surgery are common for Medicare patients, suggesting opportunities to improve care.  Health Aff (Millwood). 2013;32:1600-1607.

Kocher KE, Asplin BR. What is our plan for acute unscheduled care? Ann Intern Med. 2013;158:907-909.

Kocher KE, Asplin BR. Emergency department crowding 2.0: coping with a dysfunctional system. Ann Emerg Med. 2012;60:687-691.

Rabin E, Kocher K, McClelland M, et al. Solutions to emergency department ‘boarding’ and crowding are underused and may need to be legislated. Health Aff (Millwood). 2012;31:1757-1766.