Emergency Visit Common Within 30 Days of Hospital Discharge

Medscape Medical News

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