1. Clinical differences between freestanding and hospital-based emergency departments
May 18, 2017
Ryan C. Burke, MPH

2. Freestanding Emergency Departments (FEDs)
“A facility that is structurally separate and distinct from a hospital and provides emergency care”1
Open 24/7 and staffed by qualified emergency care providers
Popularity and number of FEDs significantly increasing2

3. FED vs. HBED Patients
Research on differences in patient populations limited
Acuity level3
Insurance type4
Communities they serve2
Objective: describe demographic and clinical differences between FED and HBED patients.

4. Methods Retrospective study of adult visits 7/1/2014 – 6/30/2015
Electronic health records, registration, and claims data
One HBED and 3 FEDs within same health system
Service area is urban-rural mix
Major metropolitan area population of 700,0005

5. Results: Visit Demographics
Percent of HBED Visits (N=55,909)
Percent of FED Visits (N=44,108)
P-value
Gender
<0.0001
Male
43.5%
39.5%
Female
56.5%
60.5%
Race/Ethnicity
White, non-Hispanic
59.7%
85.9%
Black, non-Hispanic
38.2%
11.8%
Other
2.1%
2.3%
Marital Status
Single
49.0%
33.6%
Now married
27.5%
41.0%
Divorced
12.1%
8.7%
Widowed
8.9%
6.1%
Separated
0.8%
Life partner
0.1%
Unemployed
50.9%
33.2%
Mean Age 48 46

6. Results: Visit Characteristics
Percent of HBED Visits (N=55,909)
Percent of FED Visits (N=44,108)
P-value
Emergency Severity Index Level
<0.0001
Level 1
1.6%
0.1%
Level 2
26.4%
5.0%
Level 3
44.8%
54.6%
Level 4
24.1%
39.7%
Level 5
3.1%
0.5%
Arrival Method
Car/Motorcycle
60.1%
88.0%
Emergency services
25.7%
5.9%
Ambulatory
11.1%
4.8%
Other
3.0%
1.3%
Insurance Type
Commercial
19.6%
42.9%
Medicaid
41.5%
24.8%
Medicare
29.7%
22.5%
Uninsured
6.0%
5.5%
4.4%

7. Cont’d: Visit Characteristics
Percent of HBED Visits (N=55,909)
Percent of FED Visits (N=44,108)
P-value
Condition on Arrival
<0.0001
Good
34.5%
31.1%
Stable
56.8%
64.0%
Fair
6.1%
4.1%
Serious
1.0%
0.4%
Critical
1.3%
0.3%
Expired
0.1%
Patient Admitted
29.5%
8.3%

8. Results: Presenting Problems
Percent of
HBED Visits
FED Visits
P-value
Gastrointestinal
19.0%
18.1%
0.0004
Cardiorespiratory
18.4%
16.1%
<0.0001
Extremity injury-pain-swelling
14.2%
16.9%
Non-specific musculoskeletal trauma
13.1%
17.6%
General medical
12.8%
9.3%
EENT and Dental
10.1%
6.3%
Skin
4.5%
6.8%
Genitourinary
4.9%
.9992
Neurology
4.6%
1.0%
Psychiatry
2.0%
.6448
Laceration
1.9%
.8463
Infection
1.8%
1.7%
.0464
Obstetrics/gynecology
1.1%
Mouth and teeth
0.4%
Head injury (minor)
0.6%

9. Results: Primary ICD-9 Code
Clinical Classification Software Category6
Percent of
HBED Visits
FED Visits
P-value
Injury and poisoning
17.7%
25.4%
<0.0001
Diseases of the respiratory system
9.4%
12.1%
Symptoms; signs; and ill-defined conditions and factors influencing health status
10.1%
9.7%
.0113
Diseases of the musculoskeletal system and connective tissue
9.3%
.0218
Diseases of the circulatory system
11.0%
7.0%
Diseases of the digestive system
8.6%
8.1%
.0016
Diseases of the nervous system and sense organs
7.3%
7.8%
.0070
Diseases of the genitourinary system
7.2%
7.9%
Mental illness
5.9%
1.5%
Diseases of the skin and subcutaneous tissue
3.3%
4.2%
Infectious and parasitic diseases
3.4%
2.4%
Endocrine; nutritional; and metabolic diseases/immunity disorders
1.8%
Complications of pregnancy; childbirth; and the puerperium
1.4%
.7299
Residual codes; unclassified; all E codes
0.7%
Diseases of the blood and blood-forming organs
0.8%
0.2%
Neoplasms
0.5%
Congenital anomalies
<0.1%
.1492

10. Conclusions Patients triaging themselves HBED visits higher acuity
FED lower admittance rate
Little variation in presenting problem and ICD9 code

11. References
American College of Emergency Physicians. Freestanding emergency departments: Policy statement. Ann Emerg Med. 2014;64:562.
Schuur JD, Baker O, Freshman J, Wilson M, Cutler DM. Where do freestanding emergency departments choose to locate? A national inventory and geographic analysis in three states. Ann Emerg Med [epub ahead of print]. doi: /j.annemergmed
Simon EL, Kovacs M, Jia Z, Hayslip D, Orlik K, Jouriles N. A comparison of acuity levels between 3 freestanding and a tertiary care ED. Am J Emerg Med. 2015;33(4): doi: /j.ajem
Simon EL, Griffin G, Orlik K, et al. Patient Insurance Profiles: A Tertiary Care Compared to Three Freestanding Emergency Departments. J Emerg Med. 2016;51(4): doi: /j.jemermed
Annual Estimates of the Resident Population: April 1, 2010 to July 1, U.S. Census Bureau, Population Division. Updated March Accessed February 2017.
Elixhauser A, Steiner C, Palmer L. Clinical Classifications Software (CCS), U.S. Agency for Healthcare Research and Quality. Available:

12. Co-Authors Erin L. Simon, DO1,3 Brian Keaton, MD1 Laura Kukral, MBA4
Nicholas J. Jouriles, MD1,3

13. Questions? Ryan Burke, MPH burker@ccf.org rburke11@kent.edu