This report examines the evolving role of hospital emergency departments (EDs) in the U.S. health care system. RAND conducted the study at the request of the Emergency Medicine Action Fund to develop a comprehensive picture of how EDs contribute to modern health care and to suggest how ED care might be more effectively, and more cost-effectively, integrated with community care.

The hospital ED is a relatively recent phenomenon that emerged in the years following World War II (A. L. Kellermann & Martinez, 2011). Beginning in the early 1970s and accelerating through the 1980s and 1990s, ED staffing shifted from part-time coverage...

To conceptualize the various ways a patient with a new health problem or worsening chronic condition weighs options for care and navigates the health care system, we developed a logic model (see Figure 2.1). It draws on previous logic models built around patient decisionmaking and the operation of hospital EDs (Asplin et al., 2003 2012; Pitts et al., 2010; Uscher-Pines, Pines, Kellermann, Gillen, & Mehrotra, 2013). Specifically, we linked the Uscher-Pines model of patient choice with the Asplin model of ED input-throughput-output to determine the various options available to a typical patient. We have added a referral component, since primary care...

Our project is primarily a quantitative analysis, supplemented by qualitative focus groups and interviews to provide context and potential explanations for our main observations. We obtained quantitative data from five nationally representative surveys (Owens et al., 2010). We obtained qualitative data from focus group discussions with ED physicians and hospitalists, and from individual interviews with primary care providers.

Our data were drawn from five public-access data sets:

The NHDS, conducted annually by the CDC’s National Center for Health Statistics (NCHS), covers discharges from non-institutional hospitals located in the 50 States and the District of Columbia.² The original sampling frame consisted...

In this chapter, we present the results of our quantitative analyses, and describe the major themes that emerged from our focus groups and individual interviews.⁶ Our presentation of findings generally tracks the order of our study aims, but in this section we use specific questions to focus attention on individual aspects of our results.

What are the most important sources of inpatient admissions and how have they changed?

Between 2003 and 2009, the U.S. population grew at a rate of about 5.7 percent, from 290.8 million in 2003 to 307.4 million in 2009 (U.S. Census Bureau, 2012). During the same...

The high costs and less-than-ideal outcomes produced by America’s health care system have led policymakers and payers to examine the value of various tests, treatments, and procedures (Morgan et al., 2012). In this context, value is generally defined as “health outcomes achieved per dollar spent” (Morgan et al., 2012; Porter, 2010; Porter & Teisberg, 2006).

Measurement of value in health care is relatively new and depends, in large part, on whether it is determined from the viewpoint of patients, insurers, or society. Patients want, most of all, to have a good treatment outcome and to be free from harm. Those who...

EDs are becoming an increasingly important source of hospital admissions. Since 2003, virtually all of the growth in inpatient admissions was driven by a strong increase in admissions from EDs. This more than offsets a decline in admissions from doctors’ offices and other outpatient clinics. By 2009, more than half of all inpatient admissions were entering the hospital through the ED. The strongest growth of inpatient admissions has been among Medicare beneficiaries, six in ten of whom are admitted through the ED. Admissions of privately insured patients have declined, largely because the number of individuals covered by employer-sponsored health insurance...