Returned and Admitted = Bad Care?

Do patients discharged from the ED who return and are admitted reflect poor quality ED care?  This is currently a hospital performance measure and ED quality of care metric.  Is this a fair metric?  Authors found that patients admitted after initial ED discharge had "lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay" compared with patients admitted on their initial visit.  We would expect that if important diagnoses were missed necessitating the return visit to the ED that patients would have worse outcomes.  In fact, they do much better, suggesting that a return ED visit doesn't mean the hospital or ED did a bad job the first time. The editorial says, "The important question in the era of electronically enabled reporting is whether the return visit rate can be used as a marker of ED quality. The simple answer, long suspected and now clearly proven in the report by Sabbatini and colleagues in this issue of JAMA, is no."

Bottom line: this is a crummy quality metric.  Want a real metric on the emergency department? Take a look at how often beds (and care) have to be rationed, leaving potentially sick people sitting in the waiting room.  Take a look at hospital priorities.  Follow the money. Are patients who earn the hospital less money kept waiting for bed space and placed at risk (ED boarding) and patients who make the hospital more money (elective surgery) given preference?

JAMA. 2016 Feb 16;315(7):663-71. doi: 10.1001/jama.2016.0649.

In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department.

Sabbatini AK1, Kocher KE2, Basu A3, Hsia RY4.

Author information:

1Division of Emergency Medicine, University of Washington, Seattle.

2Department of Emergency Medicine, University of Michigan, Ann Arbor3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

3Department of Health Services and Economics, University of Washington, Seattle.

4Department of Emergency Medicine, University of California, San Francisco6Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco.

Comment in

Abstract

IMPORTANCE:

Unscheduled short-term return visits to the emergency department (ED) are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care.

OBJECTIVE:

To examine in-hospital clinical outcomes and resource use among patients who are hospitalized during an unscheduled return visit to the ED.

DESIGN, SETTING, AND PARTICIPANTS:

Retrospective analysis of adult ED visits to acute care hospitals in Florida and New York in 2013 using data from the Healthcare Cost and Utilization Project. Patients with index ED visits were identified and followed up for return visits to the ED within 7, 14, and 30 days.

EXPOSURES:

Hospital admission occurring during an initial visit to the ED vs during a return visit to the ED.

MAIN OUTCOMES AND MEASURES:

In-hospital mortality, intensive care unit (ICU) admission, length of stay, and inpatient costs.

RESULTS:

Among the 9,036,483 index ED visits to 424 hospitals in the study sample, 1,758,359 patients were admitted to the hospital during the index ED visit. Of these patients, 149,214 (8.5%) had a return visit to the ED within 7 days of the index ED visit, 228,370 (13.0%) within 14 days, and 349,335 (19.9%) within 30 days, and 76,151 (51.0%), 122,040 (53.4%), and 190,768 (54.6%), respectively, were readmitted to the hospital. Among the 7,278,124 patients who were discharged during the index ED visit, 598,404 (8.2%) had a return visit to the ED within 7 days, 839,386 (11.5%) within 14 days, and 1,205,865 (16.6%) within 30 days. Of these patients, 86,012 (14.4%) were admitted to the hospital within 7 days, 121,587 (14.5%) within 14 days, and 173,279 (14.4%) within 30 days. The 86,012 patients discharged from the ED and admitted to the hospital during a return ED visit within 7 days had significantly lower rates of in-hospital mortality (1.85%) compared with the 1,609,145 patients who were admitted during the index ED visit without a return ED visit (2.48%) (odds ratio, 0.73 [95% CI, 0.69-0.78]), lower rates of ICU admission (23.3% vs 29.0%, respectively; odds ratio, 0.73 [95% CI, 0.71-0.76]), lower mean costs ($10,169 vs $10,799; difference, $629 [95% CI, $479-$781]), and longer lengths of stay (5.16 days vs 4.97 days; IRR, 1.04 [95% CI, 1.03-1.05]). Similar outcomes were observed for patients returning to the ED within 14 and 30 days of the index ED visit. In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit.

CONCLUSIONS AND RELEVANCE:

Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay. These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.

PMID: 26881369 [PubMed - indexed for MEDLINE]

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