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Variation in Hospitalizations From ERs Offers Opportunity to Save Billions, Authors Say

Too many common, low-mortality conditions lead to hospital stays

It sounds like the setup for a joke: Two identical patients go to two different hospital emergency entrances, complaining of the same symptoms.

But what happens next is no laughing matter, according to a new study from the University of Michigan, published in the September issue of Health Affairs. While one patient may get treated and released from the emergency department, the other gets sent upstairs to a hospital bed — at a cost of tens of thousands of dollars.

In fact, doctors at one hospital may be as much as six times more likely to admit an emergency patient with a common non–life-threatening diagnosis to the hospital, compared with doctors at another hospital treating an identical patient.

This variation in decision-making about hospitalizing emergency patients with the same non–life-threatening condition may cost an extra $5 billion a year, the authors estimate, depending on different assumptions.

“Our data reveal widely varying decision-making about hospitalization for patients who come to the emergency department with symptoms such as chest pain, asthma flare-ups, an infected wound, or a urinary tract infection,” said senior author Keith Kocher, MD, MPH. “This suggests tremendous opportunity for care improvement and cost reduction, and even the chance to turn the ED into a workshop for new forms of care coordination and alternatives to acute hospitalization for such patients.”

Kocher and his colleagues analyzed national data on 28.5 million emergency visits to 961 hospitals in 2010 by adults with 15 different common conditions and any form of insurance. Just over 15% of the visits resulted in a patient being admitted to the hospital — at an average cost of nearly $35,000 each.

For patients with a life-threatening condition — such as a heart attack, acute kidney failure, or sepsis — the researchers found little variation between hospitals in the decision to admit them or to transfer them to another hospital for admission.

But for patients with chest pain and no heart attack, the odds of getting admitted ranged widely, especially when the researchers factored out the patients’ other health conditions, age, gender, and insurance status.

Patients at the hospitals with the highest rates of admissions for that condition were 6.55 times more likely to be hospitalized than were patients treated at the hospitals with the lowest admission rates.

The variation was smaller for patients with soft-tissue infections or asthma flare-ups. But some hospitals were three times more likely to admit them than others, the researchers found after factoring out other variables.

For patients experiencing symptoms of emphysema or chronic bronchitis (collectively termed chronic obstructive pulmonary disease [COPD]), or a urinary tract infection, the chances of admission varied more than twofold, depending on what hospital they went to.

All five of these conditions with high variations in post-emergency hospitalizations had very low in-hospital death rates, Kocher noted. The COPD patients had the highest chance of dying before leaving the hospital, at just over 1%, and the chest pain patients had only a 0.05% death rate. By contrast, nearly 15% of the sepsis patients died during the hospital stay that followed their emergency visit.

The total charges for caring for patients hospitalized from the emergency department for all 15 conditions exceeded $266 billion a year, the researchers calculated, although hospitals likely received approximately $80 billion once the bills were actually paid by insurers, Medicaid, or Medicare — or left unpaid by the 18% of patients in the study who were uninsured.

“These results suggest there may be sizeable savings to U.S. payers if differences in post-emergency hospitalization practices could be narrowed among a few of these high-variation, low-mortality conditions,” the authors write.

Source: University of Michigan Health System; September 8, 2014.

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