Assessing the impact of environmental factors on emergency healthcare quality: A benchmarking approach

Evaluating the quality of emergency departments in hospitals is crucial for optimizing healthcare and allocating resources effectively. Existing metrics predominantly focus on internal variables (e.g., bed occupancy or time to treatment), disregarding possible external environmental factors beyond their control. In order to address this issue, in this paper we have a threefold objective. First, we introduce a Quality Composite Indicator (QCI) for benchmarking emergency departments quality, considering the specific impact of demographic, socio-economic, and behavioral factors. This metric minimizes the influence of outliers, facilitating a comparison among emergency departments, and enabling the identification of top performers based on quality indicators. Second, our study, conducted across 85 health trusts in England, reveals that emergency departments in areas with higher population density, a larger elderly population, increased birth rates, and more disadvantaged households generally provide lower-quality services. Furthermore, a higher incidence of depression and anxiety, combined with elevated crime levels, further worsens the quality of urgent healthcare services in these regions. Third, our analysis highlights differences in how certain environmental factors affect overall hospital performance versus specialized units like emergency departments. These results uncovered significant regional disparities in healthcare quality, contradicting the goal of nationwide uniformity. • Develops a robust Benefit-of-the-Doubt Quality Composite Indicator (QCI) for emergency departments, integrating the five quality indicators and reducing sensitivity to outliers. • Extends the QCI using conditional order-m techniques to account for demographic, socio-economic, and behavioural environmental factors beyond hospitals’ control. • Shows that higher population density, ageing, birth rates, deprivation, mental ill-health and crime are strongly associated with lower measured ED quality, while income, education and unemployment play a limited role. • Reveals persistent regional inequalities in emergency care quality within NHS England and discusses implications for equity-sensitive benchmarking and budget allocation.