ORIGINAL ARTICLE What Affects Time to Care in Emergency Room Appendicitis Patients? Nina A. Bickell, MD, MPH,*† Ula Hwang, MD, MPH,‡ Rebecca M. Anderson, MPH,* Mary Rojas, PhD,* and Carol L. Barsky, MD‡ Background: Emergency departments (EDs) provide a safety net for seriously ill individuals. Little is known about factors that affect time to diagnosis and treatment of patients with time-sensitive conditions within the ED. Methods: Retrospective observational study of 236 appendicitis patients examining patient factors and ED characteristics with time to a surgeon’s diagnosis of appendicitis and ED length of stay (LOS). Results: Time to surgeon’s diagnosis and ED LOS were slower for nonwhite patients without private insurance (parameter estimate = 0.38, P = 0.002 and 0.31, P  0.001, respectively) and quicker for patients for whom the ED physician’s diagnostic first impression was appendicitis (parameter estimate =-0.29, P = 0.003 and -0.14, P = 0.04, respectively). Greater numbers of physicians staffing the ED had a modest effect on time to surgeon diagnosis and ED LOS (parameter estimate =-0.04, P = 0.01 and -0.04, P = 0.01, respectively), whereas greater numbers of patients had little impact (parameter estimate =-0.005, P = 0.04 and -0.002, P = 0.28, respectively). Conclusions: Minority patients without private insurance had slower times to specialist consultation and treatment; ED staffing and census had a small effect. To maximize patient safety and ED quality of care, administrators should ensure timely specialist con- sultation and determine additional mechanisms facilitating white privately insured patients’ quicker care. Key Words: emergency, staffing, quality of care, time, appendicitis (Med Care 2008;46: 417– 422) O ur society depends on accessible, responsive, and high quality emergency medical care. The increasing use of, overcrowding, and understaffing of emergency departments (EDs) poses a potential threat to the public’s safety and well-being. 1–4 The effect of various EDs and patient-related factors, however, on the quality and timeliness of care deliv- ered in the emergency room is uncertain. 5–14 Studies have demonstrated racial and ethnic disparities for cardiac, stroke, asthma, and pain care in the ED setting with nonwhite patients more likely to have missed myocardial infarctions, less likely to receive tissue-type plasminogen activator for suspected ischemic stroke, receive less anti-inflammatory inhaled medications for asthma, and inadequate analgesia for pain. 15–20 In addition, well-insured patients have better access to emergency departments and to needed care after emer- gency visits. 21,22 In contrast, appendicitis patients with Med- icaid or no insurance experience higher rates of rupture but whether this was due to delays getting to or the quality of care within the ED was not determined. 21 We sought to evaluate a relatively common, urgent, time-sensitive condition for which time to diagnosis and treatment could be quantified and delays in treatment are directly related to a poorer health outcome. Appendicitis is an urgent condition for which shorter times to treatment are associated with lower risks of rupture. 23 More importantly, appendicitis is a condition that does not typically have a designated center or pathway for care (ie, myocardial infarc- tion or stroke that often have specialized teams to minimized “door to needle times”) and thus, could illustrate the effects of working conditions on time to care. We undertook this study to determine whether patient-related factors such as race, disease severity or insurance; physician-related factors such as diagnostic impression of appendicitis; and system- related factors such as availability of specialist consultation, and staffing levels of ED physicians, nurses, or support personnel affect time to treatment among patients with a time-sensitive condition, appendicitis. METHODS Study Setting The study was conducted in an urban, 1171-bed, aca- demic medical center. IRB approval was obtained for this project. The ED has 46 beds, averages about 80,000 patient visits annually and 200 visits per day. Study Design and Participants The study sample comes from a previous study dem- onstrating worse health outcomes with increasing time among patients with time-sensitive conditions. 23–25 In that study, 242 patients with appendicitis, admitted between June 1, 2001 and November 30, 2002, were identified in real time and eligible From the Departments of *Health Policy; †Medicine; and ‡Emergency Medicine, Mount Sinai School of Medicine, New York, New York. Reprints: Nina A. Bickell, MD, MPH, Departments of Health Policy and Medicine, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1077, New York, NY 10029. E-mail: nina.bickell@mssm.edu. Copyright © 2008 by Lippincott Williams & Wilkins ISSN: 0025-7079/08/4604-0417 Medical Care • Volume 46, Number 4, April 2008 417