Ensuring safe transitions of care is an important goal for promoting better patient experiences, improving the quality of outcomes, and reducing costs. All-cause hospital readmissions are now a reportable measure of hospital quality and tied to financial penalties for poor-performing hospitals. Unscheduled return visits after ED discharge may also be a reflection of inadequate discharge practices or follow-up procedures.
“Throughout the United States, short-term unscheduled return visits to the ED are being monitored as an administrative performance measure,” says Amber K. Sabbatini, MD, MPH. “However, there may be unintended consequences from using return visits to the ED as a measure of quality.” When deciding whether or not to hospitalize patients, emergency physicians need to balance expected benefits of hospitalization against clinical uncertainty, the risks associated with admitting patients, and the costs of hospital stays. To date, little is known about the subsequent clinical outcomes of patients who have had a return visit to the ED and subsequent hospital admission.
Taking a Closer Look
For a study published in JAMA, Dr. Sabbatini and colleagues examined in-hospital clinical outcomes and resource use among patients who were admitted to the hospital on a return visit to the ED and compared them with patients who were hospitalized and did not return to the ED. The authors hypothesized that patients with a return visit to the ED would be more likely to return with severe symptoms or at a later stage of their acute illness. This may mean that these patients could experience relatively poorer outcomes and use more resources during their hospitalization as a result of delayed care.
Using data from the Healthcare Cost and Utilization Project, the investigators retrospectively reviewed adult ED visits to acute care hospitals in Florida and New York in 2013. Patients with index ED visits were identified and followed for return visits to the ED within 7, 14, and 30 days. Among the more than 9 million index ED visits to 424 hospitals in the study sample, more than 1.7 million patients were admitted to the hospital during the index ED visit.
Of the patients who were initially admitted to the hospital during their index ED visit, 8.5% had a return visit to the ED within 7 days of the index ED visit and 51.0% were readmitted. The research team also found that 13.0% of these patients had a return visit to the ED within 14 days of the index ED visit and 53.4% were readmitted to the hospital. In addition, 19.9% of these patients had a return visit to the ED within 30 days of the index ED visit and 54.6% were readmitted.
According to Dr. Sabbatini, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission. “These patients also had longer lengths of stay and higher costs during the repeat hospital admission when compared with those admitted to the hospital during their index ED visit without a return ED visit,” she says. Results were consistent for patients returning to the ED within 7, 14, or 30 days of their initial ED visit (Table).
“Our findings suggest that ED return admissions may not adequately capture deficits in the quality of care that is delivered during an ED visit,” adds Dr. Sabbatini. “The interpretation of rates of return visits to the ED has important policy implications, especially with the recent efforts to provide patients with a value-driven healthcare system.” The study notes that recent changes in healthcare financing—such as payer scrutiny over short-stay hospitalizations, physician profiling with pay-for-performance incentives or penalties, and expansion of risk-sharing agreements—have increased pressure on hospitals and physicians to reduce unnecessary admissions.
“There is value in tracking ED return visits as an internal quality assurance process, but it doesn’t appear to be prudent to emphasize ED return visits as a blunt measure of quality when assessing hospital performance,” Dr. Sabbatini says. “Such policies may encourage unnecessary hospitalizations as emergency physicians try to guard themselves against clinical uncertainty and maintain favorable revisit metrics.”
Dr. Sabbatini says that choosing appropriate measures that accurately identify the quality of ED care will be increasingly important so that physicians and hospitals are incentivized in a way that benefits patients while avoiding unintended consequences. “Decisions to discharge patients from the ED also depend on patient preferences and their ability to safely manage their condition as an outpatient,” she says. “Many factors could play a role on ED revisit rates. When it comes to treatment, the key is for physicians to do their due diligence and share the decision-making process with patients. We should strive to strike a balance between safe discharge practices and appropriate stewardship of hospital-based resources.”
Sabbatini AK, Kocher KE, Basu A, Hsia RY. In-hospital outcomes and costs among patients hospitalized during a return visit to the emergency department. JAMA. 2016;315:663-671.Available at: http://jama.jamanetwork.com/article.aspx?articleid=2491638.
Sabbatini AK, Nallamothu BK, Kocher KE. Reducing variation in hospital admissions from the emergency department for low-mortality conditions may produce savings. Health Aff (Millwood). 2014;33:1655-1663.
Rising KL, White LF, FernandezWG, Boutwell AE. Emergency department visits after hospital discharge: amissing part of the equation. Ann Emerg Med. 2013;62:145-150.
Rising KL, Victor TW, Hollander JE, Carr BG. Patient returns to the emergency department: the time-to-return curve. Acad Emerg Med. 2014;21:864-871.