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

Quyen Bach, Mercer University College of Pharmacy

 

It is suggested that short-term unscheduled return visits to the emergency department (ED) have become more commonly used as an administrative performance measure and as a broader measure of the quality of emergency care, particularly if the patient requires hospitalization during the return ED visit.1

To date, it has been stated that little is known about the subsequent clinical outcomes of patients who have had a return visit to the ED and subsequent hospital admission.2

In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department2
Design Retrospective; N = 1,771,308
Objective To examine in-hospital clinical outcomes and resource use among patients who had a return visit to the ED and subsequent hospital admission compared to patients who were hospitalized and did not experience a return visit to the ED
Study Groups Hospital admission without ED revisit (n = 1,609,145); revisit to ED (n = 162,163)
Methods Chart reviews of adult patients with ED visits to hospitals in Florida and New York were performed using data from the Healthcare Cost of Utilization Project of the Agency for Healthcare Research and Quality.
Duration 2013
Primary Outcome Measure (1) In-hospital mortality, (2) intensive care unit (ICU) admission, (3) length of stay, and (4) total inpatient costs
Baseline Characteristics     Revisit to ED
  Hospital Admission Without ED revisit (n = 1,609,145) ED Return Admission (n = 86,012) Readmission (n = 76,151)
Mean age (yr) 64.0 54.9 66.4
Female sex (%) 52.7 53.3 50.0
Race (%)      
White 62.3 59.0 62.2
Black 16.3 18.6 17.0
Others 21.4 22.4 20.8
≥ 2 Comorbidities (%) 71.1 62.3 81.3
Primary payer (%)      
Medicare 57.6 39.4 65.8
Medicaid 13.3 21.3 14.7
Private 18.9 12.8 5.2
Others 10.2 26.5 14.3
High use of ED (%) 12.6 31.3 34.8
Results     Revisit to ED
  Hospital Admission Without ED revisit (n = 1,609,145) ED Return Admission (n = 86,012) Readmission (n = 76,151)
Died in hospital (%) 2.47 1.35 4.59
Length of stay (d)
   Median (25th-75th percentile) 3 (2-6) 3 (2-6) 4 (2-8)
   Mean (SD) 5.04 (7.00) 4.96 (6.55) 6.43 (7.63)
ICU admission (%) 29.1 21.2 33.5
Total cost ($)
   Median (25th-75th percentile) 7,102 (4,437-12,304) 6,436 (3,982-10,891) 7,824 (4,650-26,041)
   Mean (SD) 11,143 (15,841) 9,823 (13,911) 12,767 (17,214)
Adverse Events Common Adverse Events: N/A
Serious Adverse Events: N/A
Percentage that Discontinued due to Adverse Events: N/A
Study Author Conclusions 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 rate, and in-hospital costs and longer lengths of stay. These findings suggest that hospital admission associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.

 

Although this study is a good first step toward examining downstream clinical outcomes among patients who experience an admission during a return visit to the ED, it failed to look at other outcomes, such as adverse events, the use of specific procedures, and other indicators of morbidity. This study also excluded inpatient records for patients transferred in or transferred out of a hospital, some of which may have been return visits. Future studies are warranted in order to fully account for all the return visits and costs to the organization.

 

References

  1. Lindsay P, Schull M, Bronskill S, Anderson G. The development of indicators to measure the quality of clinical care in emergency departments following a modified-delphi approach. Acad Emerg Med. 2002;9(11):1131-9.
  2. Sabbatini AK, Kocher KE, Basu A, Hsia RY. In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department. JAMA. 2016;315(7):663-71.
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