Postdischarge ED Visits Nearly as Frequent as Readmissions



Among adults discharged from the hospital, visits to the emergency department within 30 days are nearly as frequent as are readmissions, according to a report in the Jan. 23/30 issue of JAMA.

In a population-based study of 30-day outcomes after hospital discharge, treat-and-release visits to the ED accounted for approximately 40% of all hospital-based acute care given in the immediate postdischarge period, said Dr. Anita A. Vashi of the Robert Wood Johnson Foundation Clinical Scholars Program and the department of emergency medicine, Yale University, New Haven, Conn., and her associates.

Dr. Anita Vashi

Readmission rates are seen as a marker of hospitals’ quality of care. Rates of ED visits following discharge also are important, but aren’t as well understood. Studies done to date "have tended to focus on the experience at a single institution, with a single payer, or with a specific condition," the investigators said.

"The use of hospital readmissions as a lone metric for postdischarge health care quality may be incomplete without considering the role of the ED," they noted.

The researchers studied the issue using data from three geographically distant states that participate in the Healthcare Cost and Utilization Project state inpatient and ED databases, using a sample of 5,032,254 discharges during a 1-year period from medical centers in California, Florida, and Nebraska. All together these states account for approximately 17% of all hospitalizations in the United States annually.

All the study subjects were adults, with a mean age of 53.4 years; 29.2% were aged 65 years and older. Slightly more than half were women, and slightly less than half were white. Most of the patients had some form of medical coverage, including private insurance (32%) and Medicare (30%). These patients were discharged after hospitalization for 470 unique conditions, 65.2% medical, 34.8% surgical. The researchers defined the ED visits as treat-and-release to separate them from visits to the ED that resulted in readmission, as about 57% of the readmissions were through the ED.

Overall, 17.9% of all discharges were followed by at least one acute-care visit to a hospital within 30 days. About one-third of all such visits – 35% of ED visits and 31% of readmissions – occurred within 7 days of discharge. A total of 7.5% of discharges were followed by at least one ED visit, and another 12.3% by a readmission. There were 97.5 ED visits and 147.6 readmissions for every 1,000 discharges.

ED visits accounted for 39.8% of the 1,233,402 postdischarge visits for acute care (JAMA 2013;309:364-71).

"Focusing solely on readmissions would have missed nearly half a million ED treat-and-release encounters in these three states and substantially underestimated acute care use following medical and surgical inpatient discharges," Dr. Vashi and her colleagues noted.

It is crucial to include such ED visits in assessments of hospitals’ quality of care because they contribute substantially to fragmentation of care with its attendant duplication of services, conflicting care recommendations, medication errors, patient distress, and higher costs, they added.

Among medical discharges, 30-day rates of ED visits were highest for digestive disorders (140.7 visits per 1,000 discharges) and psychosis (219.4 visits per 1,000 discharges). Visits for heart failure also were common.

Among surgical conditions, ED visits were most common for complicated laparoscopic cholecystectomy (84.5 visits per 1,000 discharges) and complicated cesarean deliveries (84.6 visits per 1,000 discharges). Visits following PCI with drug-eluting stent placement, for major cardiac diagnoses, and for complicated hip and femur procedures also were common.

Among the 470 unique conditions in this study, those with the highest rates of ED visits were related to mental health problems and drug and alcohol abuse.

"Anticipating patient needs and developing an appropriate care plan prior to hospital discharge may help prevent some of these likely low-acuity visits," Dr. Vashi and her associates said.

For example, "given that patients hospitalized for reasons related to mental illness and drug and alcohol abuse had especially high rates of return to the ED, there must be consideration of how acute care can be best delivered and targeted to this population outside of hospitals," they said.

The investigators cautioned that their findings underestimate the number of hospital discharges that are immediately followed by emergency care visits, because they could not include in this study patients who died before making it to the ED, went to urgent-care centers, or presented at walk-in clinics.

This study was supported in part by the Agency for Healthcare Research and Quality, the National Institute on Aging, and the American Federation for Aging Research. Dr. Vashi reported no financial conflicts of interest, and one of her associates reported ties to Medtronic.

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