Nearly a quarter of patients may return to the ED within 30 days of a hospital discharge, according to a study.
If these subsequent ED visits do not lead to a hospital admission, the researchers noted, they are not included in calculating the hospital readmission rates that are a key focus of healthcare cost containment and quality improvement efforts.
“Hospital readmissions within 30 days of inpatient discharge are frequent and costly,” Kristin Rising, MD, the studys lead author and a research fellow at the Perelman School of Medicine at the University of Pennsylvania, said in a news release.
“But current methods of measuring readmissions are missing a large part of the picture since they only include inpatient-to-inpatient hospitalization and ignore return visits to the emergency department that do not result in admissions.”
The number of ED visits following hospital discharge may be even higher than the 23.8% rate reported in the study, the researchers said, since data collection was restricted to a single safety-net hospital in Boston. The researchers thus could not determine whether patients were treated at another hospitals ED during the study period.
The findings, published April 8 on the website of the Annals of Emergency Medicine, are important because a large number of U.S. patients receive their care from safety-net institutions such as the one in the study, the authors noted. Safety-net hospital patients are disproportionately likely to be beneficiaries of Medicare and Medicaid, and more likely to be uninsured and not have a family physician — and thus more apt to turn to the ED for care when they experience complications after being discharged from the hospital.
The Centers for Medicare & Medicaid Services has invested heavily in policies, incentives, technical assistance and new payment models to prompt providers to reduce avoidable rehospitalization, the authors noted. For example, hospitals are financially penalized for readmissions that occur within 30 days of discharge. As a result, they have undertaken a number of steps to reduce readmissions, including patient and family education, nurse check-ins and even telemonitoring once patients return home.
A major implication of the study is that ED clinicians should play an active role in efforts to reduce avoidable hospital use, Rising said.
“The large number of patient visits to the emergency department shortly after discharge — and the fact that emergency departments are increasingly the primary source of hospital admissions — means that at least part of the solution to reducing readmissions will rest with clinicians in the emergency department who are making decisions about whether to admit patients to the hospital,” Rising said.
The question of how ED providers can be most effective in breaking the readmission cycle depends upon a determination of patients greatest needs at the time of ED presentation, she added.
Researchers with the Perelman School of Medicine and Boston University School of Medicine found that nearly half of return visits — 46% — led to subsequent rehospitalization, which means they are included in readmission data. Rising and her colleagues found that heart failure was the primary diagnosis for return ED visits with both subsequent discharge and subsequent readmission.
After heart failure, the clinical patterns diverged: The top three diagnoses for return ED visits with subsequent discharge were diabetes with complications, complications of a device and pneumonia; the top three diagnoses for return ED visits with subsequent readmission were complications of a device, sickle cell anemia and abdominal pain.
“These findings indicate that initiatives to address recurrent hospital use may need to vary, depending on the types of recurrent visits being targeted,” Rising said.
The study abstract is available at www.annemergmed.com/article/S0196-0644%2813%2900096-6/abstract.