Practice Economics

ED revisits twice as frequent as expected

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Highlighting an underappreciated problem

The findings of Duseja et al. highlight an underappreciated problem and also raise important questions.

To what extent do ED revisits represent gaps in quality as opposed to reasonable strategies that prevent admissions? How often are revisits due to failures of transitional care, suboptimal patient education, or lack of timely follow-up? And why do patients so often seek care at different institutions? Are they dissatisfied with their initial encounter, exercising greater discretion in choosing a facility the second time around, or doing something else?

Dr. Kumar Dharmarajan and Dr. Harlan M. Krumholz are at the Center for Outcomes Research and Evaluation, Yale University, New Haven Conn. Dr. Dharmarajan reported receiving grant support from the National Institute on Aging and the American Federation for Aging Research. Dr. Krumholz reported receiving grant support from the National Heart, Lung, and Blood Institute and the Center for Cardiovascular Outcomes Research at Yale. The investigators made these remarks in an editorial accompanying Dr. Duseja’s report (Ann. Intern. Med. 2015 June 1 [doi:10.7326/M15-0878]).



The rate of adult revisits to emergency departments is more than twice as high as has been reported previously – 8% at 3 days and 20% at 30 days – in large part because until now researchers have failed to account for revisits to different hospitals, according to a report published online June 1 in Annals of Internal Medicine.

Little is known about returns to an emergency department following an index ED visit because most studies have assessed only visits to a single institution or to hospitals within a single state or insurance plan. Now researchers have performed a broader examination of the issue by analyzing newly available multistate longitudinal data from the Healthcare Cost and Utilization Project, which allowed them to identify returns to any ED or acute-care hospital. They focused on acute-care revisits after 57,530,239 initial ED visits by adults in six states (Arizona, California, Florida, Nebraska, Utah, and Hawaii) during 2006-2010.


At 3 days after an initial ED visit, the overall revisit rate was 8.2%, with one-third of these revisits occurring at a medical facility different from that of the initial visit. Previously, estimates of 3-day revisits have ranged from 2.7% to 3.4%. At 30 days, the revisit rate was 20%, and approximately one-third of these revisits involved a different facility. Revisits to different institutions “may have special clinical and financial implications because fragmentation of care increases the likelihood of duplication of services and problems with care transitions,” said Dr. Reena Duseja of the department of emergency medicine, University of California, San Francisco, and her associates.

“The scope of revisits to outside institutions is much greater than previously suspected, which suggests that improving communication infrastructure across institutions (such as health information exchanges) may improve care and allow individual institutions to get a more accurate picture of their revisit rates,” they noted (Ann. Intern. Med. 2015 June 1 [doi:10.7326/M14-1616]).

Revisit rates varied substantially according to diagnosis. “Skin and subcutaneous tissue infection”accounted for 23% of revisits. “Abdominal pain” was the diagnosis with the next highest revisit rate (10%). The most frequent diagnosis among patients who revisited a different hospital was back pain (2.6%), and nonspecific chest pain was the diagnosis with the highest rate of later admission to a different hospital (1.1%).

Financial data from the Florida facilities showed that revisits accounted for more of the total costs of ED care than initial visits did. This demonstrates that revisits are a major, and unaccounted for, component of emergency care costs, Dr. Duseja and her associates said.

Because of insufficient data, they could not determine whether these revisits reflected inadequate access to primary care, patient nonadherence to treatment recommendations, poor quality of care at the initial visit, or other factors, the researchers noted.

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