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Study Shows 25% of Patients Discharged From Hospitals Return to EDs Within 30 Days

ED visits go unreported in calculating hospital readmissions (Apr. 16)

A study led by researchers at the University of Pennsylvania’s Perelman School of Medicine and at the Boston University School of Medicine has found that nearly one quarter of patients may return to the emergency department (ED) within 30 days of being discharged from a hospitalization. If these emergency room visits do not lead to subsequent admissions, however, they are not included in calculating hospital readmission rates — a key focus of health-care cost containment and quality improvement efforts. The new findings were published in the Annals of Emergency Medicine.

According to the authors, the number of ED visits following hospital discharge may be even higher than the rate they found, since data collection was restricted to information from a single “safety net” hospital in Boston — meaning that there was no way to determine whether patients were treated at another hospital’s ED during the study period.

“Hospital readmissions within 30 days of inpatient discharge are frequent and costly,” said lead author Kristin Rising, MD. “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 new findings are important because a large number of U.S. patients receive their care from safety-net institutions such as the one studied, the authors noted. Safety-net hospital patients are disproportionately likely to be beneficiaries of Medicare and Medicaid, and they’re more likely to be uninsured and not to have a family physician — and therefore are more apt to turn to the ED for care when they experience complications after being discharged from the hospital.

The federal government, principally the Centers for Medicare & Medicaid Services (CMS), has invested heavily in policies, incentives, technical assistance, and new payment models to prompt providers to reduce avoidable rehospitalization, the authors say. For example, under pay-for-performance, 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 new study is that ED clinicians should play an active role in efforts to reduce avoidable hospital use. “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,” said Rising. The question of how ED providers can be most effective in breaking the readmission cycle depends on a determination of patients’ greatest needs at the time of ED presentation, she added.

The study found that nearly half of return visits — 46% — led to subsequent rehospitalization, which means that they were included in readmission data. Rising and her colleagues found that congestive heart failure was the primary diagnosis for return ED visits with both subsequent discharge and subsequent readmission. After heart failure, the clinical patterns diverge: the top three diagnoses for return ED visits with subsequent discharge were diabetes with complications, complications of a device, and pneumonia. In contrast, 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,” said Rising.

Source: Penn Medicine; April 16, 2013.

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