Laurie Barclay, MD
Jan 22, 2013
Emergency department (ED) visits within 30 days after acute care
hospital discharge were common among adults, accounting for 39.8% of
hospital-based acute care visits after discharge, according to a prospective
study published in the January 23/30 issue of JAMA.
"Current efforts to improve health care 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," write
Anita A. Vashi, MD, MPH, from the Robert Wood Johnson Foundation Clinical
Scholars Program and the Department of Emergency Medicine, Yale University
School of Medicine, and Department of Veterans Affairs/VA Connecticut
Healthcare System, West Haven, and colleagues "[ED] visits are also a
marker of hospital-based acute care following discharge but little is known
about ED use during this period."
The study goals were to assess the extent to which ED visits and
hospital readmissions contribute to overall use of acute care services within
30 days of discharge from acute care hospitals, to identify the causes
underlying return for ED visits, and to compare these patterns among Medicare
beneficiaries with those among patients not covered by Medicare.
The study cohort consisted of 4,028,555 patients at least 18 years of
age (mean, 53.4 years) who were recorded in the Healthcare Cost and Utilization
Project state inpatient and ED databases. Between July 1, 2008, and September
31, 2009, these patients had a total of 5,032,254 discharges from acute care
hospitals in California, Florida, and Nebraska.
One or more acute care encounters in the 30 days after discharge
occurred in 17.9% (95% confidence interval [CI], 17.9% - 18.0%) of
hospitalizations. ED visits made up 39.8% (95% CI, 39.7% - 39.9%) of these
1,233,402 postdischarge acute care encounters. In the 30 days after discharge,
there were 97.5 (95% CI, 97.2 - 97.8) ED treat-and-release visits and 147.6
(95% CI, 147.3 - 147.9) hospital readmissions per 1000 discharges.
The lowest number of ED treat-and-release visits per 1000 discharges was
22.4 (95% CI, 4.6 - 65.4) for breast cancer, and the highest was 282.5 (95% CI,
209.7 - 372.4) for uncomplicated benign prostatic hypertrophy. Among the
highest-volume discharges, the most common reason for the return ED visits was
always related to their index hospitalization.
"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 study authors conclude.
In an accompanying editorial, Mark V. Williams, MD, from the
Northwestern University Feinberg School of Medicine in Chicago, Illinois, noted
that digestive disorders and psychosis were the highest-volume reasons for
30-day posthospital discharge ED treat-and-release visit rates, rather than the
3 diseases currently measured by Centers for Medicare & Medicaid Services
for 30-day readmissions among Medicare beneficiaries.
"Comprehensive efforts to identify and mitigate risk factors for
subsequent unnecessary health care use after hospital discharge will likely be
worthwhile," Dr. Williams writes. "Developing care process approaches
that serve patients and ensure adequate coordinated care should be the goal.
Visits to the ED after hospitalization should also be monitored and assessed as
a quality measure to complement 30-day readmissions."
One coauthor received support from the Agency for Healthcare Research
and Quality. One coauthor received support from the National Institute on Aging
and the American Federation for Aging Research through the Paul B. Beeson
Career Development Award Program. Some of the study authors reported various
disclosures involving the Office of the Assistant Secretary for Preparedness
and Response, the Centers for Medicare & Medicaid Services, the Pew
Charitable Trusts, the Yale University Open Access project, and/or FAIR Health
Inc. Dr. Vashi and Dr. Williams have disclosed no relevant financial
relationships.
JAMA. 2013;309:364-371.
Abstract
