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Many patients need acute care after discharge

Wednesday January 23, 2013
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In a study that included more than 4 million patients, nearly 20% of hospitalizations resulted in an acute care encounter within the 30 days following discharge, with ED visits accounting for about 40% of post-discharge hospital-based acute care use.

"Hospital readmissions within 30 days of discharge are common, costly and often related to the index hospitalization," researchers wrote in background information for the study, which appears in the Jan. 23/30 issue of the Journal of the American Medical Association.

"Current efforts to improve healthcare focus on hospital readmission rates as a marker of quality and on the effectiveness of transitions in care during the period after acute care is received. Emergency department visits are also a marker of hospital-based acute care following discharge but little is known about ED use during this period."

Anita A. Vashi, MD, MPH, of the Yale University School of Medicine in New Haven, Conn., and colleagues conducted a study to determine the degree to which ED visits and hospital readmissions contribute to overall use of acute care services within 30 days of hospital discharge. The study included patients ages 18 and older (average age 53) who were discharged between July 2008 and September 2009 from acute care hospitals in three large, geographically diverse states (California, Florida and Nebraska) with data recorded in the Healthcare Cost and Utilization Project state inpatient and ED databases. The majority (53.5%) of patients were female and 48% were white.

The final study group included 5,032,254 index hospitalizations among 4,028,555 patients. The researchers found that of all the hospitalizations in the study, 17.9% resulted in at least one acute care encounter in the 30 days following discharge; 7.5% of discharges were followed by at least one ED encounter; and 12.3% by at least one readmission.

For every 1,000 discharges, there were 97.5 ED treat-and-release visits and 147.6 hospital readmissions in the 30 days following discharge. Visits to the ED comprised 39.8% of the post-discharge acute care encounters. Also, approximately a third of hospital-based acute care use occurred during the first seven days following hospital discharge, and more than half occurred during the first 14 days.

There was substantial variability in use rates of acute care across the 470 different index discharge conditions. The number of ED treat-and-release visits ranged from a low of 22.4 encounters per 1,000 discharges for breast malignancy to a high of 282.5 encounters per 1,000 discharges for uncomplicated benign prostatic hypertrophy.

"Although patients returned to the ED for a variety of reasons, for the highest-volume conditions, ED treat-and-release visits were always related to the index hospitalization," the authors wrote.

The authors concluded that "hospital-based acute care encounters are frequent among patients recently discharged from an inpatient setting. An improved understanding of how the ED setting is best used in the management of acute care needs — particularly for patients recently discharged from the hospital — is an important component of the effort to improve care transitions.

"The use of hospital readmissions as a lone metric for postdischarge healthcare quality may be incomplete without considering the role of the ED. Just as the Patient Protection and Affordable Care Act requires the development of programs to reduce readmissions, further initiatives are necessary to understand the drivers of postdischarge ED use and the clinical and financial efficiency associated with providing such acute care in the ED."

The study abstract is available at http://jama.jamanetwork.com/article.aspx?articleid=1558277#qundefined.


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