Emergency department (ED) observation units (OU) improve the use of health care resources and improve the quality of patient care. Costs increase with observation of patients who would otherwise have been released after the ED evaluation. Observation improves the quality of patient care by identifying patients whose diagnosis otherwise would be missed because they presented with atypical symptoms, for example, an acute myocardial infarction (MI) patient presenting with shortness of breath (SOB). Costs decrease with observation of patients who would otherwise have been admitted to the hospital after the ED evaluation. Observation evaluates patients for serious disease who otherwise would have been admitted to the hospital. This improves utilization because 80% of patients are found during observation to not have a serious disease and therefore can avoid hospitalization. The overall financial effect with observation is cost savings because of avoidance of hospital admissions and the avoidance of those costs.

This article examines the overall economic effect of implementing ED observation units, which varies at individual institutions depending on the physicians' threshold for hospitalization of patients. Avoiding hospitalization with observation does dramatically lower the costs to healthcare system. Most healthcare costs are due to hospitalizations, and the costs are reduced over 50% for patients managed in observation units.<sup>1DeLeon A.C., Farmer C.A., King G. Chest pain evaluation unit: A cost effective approach for ruling out myocardial infarction South Med J 1989 ;  82 : 1083-1089 [cross-ref]

Cliquez ici pour aller à la section Références, 2Dunbar L. Congestive heart failure Observation Medicine Butterworth-Heinemann, Newton, MA: Andover Medical Publisher (1993).  280

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Cliquez ici pour aller à la section Références, 6Gomez M.A., Jefferey L.A., Karagounis L.A., et al. An emergency department–based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: Results of a randomized study (ROMIO) J Am Coll Cardiol 1996 ;  28 : 25-33 [cross-ref]

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Cliquez ici pour aller à la section Références, 13Kerns J.R., Shaub T.F., Fontanarosa P.B. Emergency cardiac stress testing in the evaluation of emergency department patients with atypical chest pain Ann Emerg Med 1993 ;  22 : 794-798 [cross-ref]

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Cliquez ici pour aller à la section Références, 25Roberts R.R., Zalenski M.J., Mensah E.K., et al. Costs of an emergency department–based accelerated diagnostic protocol vs hospitalization in patients with chest pain: A randomized controlled trial JAMA 1997 ;  2787 : 1670-1676 [cross-ref]

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Cliquez ici pour aller à la section Références, 29Rydman R.J., Isola M.I., Roberts R.R., et al. Emergency department observation unit versus hospital inpatient care for a chronic asthmatic population: A randomized trial of health status outcome and cost Med Care 1998 ;  36 : 599-609 [cross-ref]

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Cliquez ici pour aller à la section Références</sup> Affects on profitability (costs versus revenue) of those participating in this healthcare reform (e.g., the payer, the physician, the hospital) is more difficult to predict given the large variability in contract negotiations between payers and providers over payment (revenue) and the variability in efficiency of clinical paths constructed in different observation units.

Even after decades of health care cost-containment activity aimed at health care, cost increases continue to be of critical concern. This article outlines the issues related to cost that affect physicians and others making patient care decisions about observation units. Many of these same issues are applicable to other areas of medicine as well. Physicians must be familiar with these concepts, because in the current practice of medicine they directly or indirectly influence everything they do.

This article begins with definitions of important economic terms, then follows with a brief review of some of the literature on observation unit cost outcomes. Clinical studies are reviewed on the cost-saving aspects of implementing an observation unit to manage selected patients with different clinical conditions. The economic impact of implementing ED observation units is reviewed from the perspective of the different participants in the health care system (e.g., hospital, payer, patient, and physician).