Return Visits to ED Twice as Frequent as Thought

Diedtra Henderson

June 02, 2015

Nearly 1 in 12 patients who visited an emergency department (ED) in six states returned to an acute care setting within 3 days, and 30 days after that first emergency visit, the revisit rate to acute care settings rose to nearly 1 in 5 patients, according to a longitudinal and population-based study. This return rate is twice as frequent as was previously reported.

Reena Duseja, MD, from the Department of Emergency Medicine, University of California, San Francisco, and coauthors report their findings in an article published in the June 2 issue of the Annals of Internal Medicine.

"Our study adds to prior work by capturing revisits outside the index institution," Dr Duseja and colleagues write. "Focusing solely on return visits to the same institution would have missed nearly 1.5 million revisits or nearly one third of all revisits in our data. Revisits that occur at a different institution may have special clinical and financial implications because fragmentation of care increases the likelihood of duplication of services and problems with care transitions."

Dr Duseja and colleagues note that because EDs are already strained, getting a handle on how often and why patients return to acute care settings may help identify interventions to curb ED revisits without imperiling patients' health. The research team tapped newly available data that permitted them to identify ED revisits, even if returning patients sought treatment at a different facility.

The authors examined data from 2006 to 2010 from six states (Arizona, California, Florida, Hawaii, Nebraska, and Utah), which represent 21.6% of the nation's population. Only 2 years of Arizona data, from 2006 and 2007, had revisit details and were included. Because 2010 data from Hawaii and Utah were not available, those years were excluded from the analysis.

Overall, the researchers identified 62.79 million index ED visits. Of those, 53.53 million included encrypted information that enabled the researchers to link subsequent ED visits and hospitalizations, and were thus included in the analysis.

Women made more than half of the visits (57.9%). In addition, the majority of patients were white (51.8%), and nearly three quarters had insurance (72.1%).

Some 8.2% of patients revisited an emergency department within 3 days of their initial visit, a percentage that rose to 19.9% at 30 days. Of those revisits, 32% occurred at a different facility than the initial ED visit, and 28% resulted in an inpatient admission.

Patients aged 18 to 44 years had slightly higher revisit rates (8.2%) than patients older than 65 years (7.8%). In terms of insurance status, patients covered by Medicaid or who were self-pay had higher revisit rates (10.1% and 9.0%, respectively) compared with patients with private insurance (6.3%).

In Florida, which had the most robust cost data, patients who returned to the ED within 30 days had costs that equaled 117.7% of all index ED costs. Skin infections and abdominal pain were the most common medical reasons for ED revisits.

In a companion editorial, Kumar Dharmarajan, MD, MBA, and Harlan M. Krumholz, MD, both from Yale School of Medicine, New Haven, Connecticut, stress that the authors "highlight an underappreciated problem...the potential preventability of revisits." They echo the study authors' call for additional research to better understand why patients revisit the ED and why one in three patients in the longitudinal study opted for treatment at a different facility.

"It may be that many are dissatisfied with their initial encounter or are exercising greater discretion in their choice of facility. The frequency at which ED revisits occur suggests that revisit measures might serve as the foundation for future performance measures," the commentators write.

Among the limitations, the study authors write, is that linkage files are kept by calendar years, so a January 2006 revisit after an ED visit in December 2005 would not be identified.

"[R]evisits are expensive and seem to be about twice as frequent as previously reported, with a substantial proportion of patients presenting to a different institution from their index ED visit," Dr Duseja and coauthors conclude. "Understanding what leads to a revisit will be an important step toward improving care and lowering costs."

Financial support for the study was provided by the Agency for Healthcare Research and Quality. The authors have disclosed no relevant financial relationships. One commentator disclosed being under contract with CMS to develop and maintain performance measures; receiving a grant from the National Heart, Lung, and Blood Institute; receiving personal fees from UnitedHealthCare; and having research agreements, through Yale, with Johnson & Johnson and Medtronic.

Ann Intern Med. 2015;162:750-756, 793-794. Article abstract, Editorial extract


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.