EDs See More Patients, Fewer Inpatient Admissions

Diana Phillips

October 15, 2018

Emergency departments (EDs) are seeing more patients, but a smaller proportion of them are being admitted to the hospital from the ED, a study has shown.

From 2006 through 2014, annual ED visits among US acute care hospitals increased by 18.4%, whereas ED admission rates saw a relative decline of 9.8%. Michelle P. Lin, MD, from the Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, and colleagues report their findings in a research letter published online October 15 in JAMA Internal Medicine.

The investigators suggest the proportionally lower hospitalization rate may be a sign that efforts to decrease hospitalization are bearing fruit. However, the author of an accompanying editorial suggests it is a sign that more people with nonemergent conditions are seeking care in the ED because of a "growing lack of access to timely primary care."

To identify trends in ED visits and admission rates in US hospitals, the investigators reviewed data from the National Emergency Department Survey collected from January 1, 2006, through December 31, 2014. They examined patient-level characteristics, including age, sex, insurance, median income, and comorbidities. They restricted their analysis to adult patients older than 18 years and excluded patients who left the ED before being seen or against medical advice or those who were transferred or died on arrival in the ED.

ED visits increased from 89.6 to 106.0 million. Total ED hospitalizations rose from 17.4 to 18.6 million, whereas ED admission rates fell from 19.4% to 17.5%. Among the additional trends, the researchers observed increases in the proportion of ED visits by patients older than 50 years, those with Medicare or Medicaid insurance, and those with one or more comorbidities. In addition,

  • Larger reductions in ED admission rates were observed among patients of increasing age.

  • ED admission rates decreased the most among Medicare-reimbursed ED visits relative to other insurance types.

  • Patients with the most comorbidities experienced the greatest decrease in ED admission rates. The decrease was by 15% among patients with at least three comorbid conditions and 11% among those with one to two comorbidities.

Given the increase in ED visits among older patients and those with comorbidities, "[O]ur findings are unlikely to be explained by lower acuity ED visits," the authors write. "In fact, ED visits with the highest burden of comorbid illness experienced the largest reductions in ED admission rates."

The authors hypothesize that declining ED admission rates — which "represent a significant reduction in hospital-based care that has received little attention to date" — may be the combined result of clinical and policy factors, including outpatient clinical pathway-based interventions designed to reduce hospital admissions, legislation-designed increased scrutiny of short-stay hospitalizations (the Recovery Audit Contractor program; the Two-Midnight Rule), and increased access to follow-up care made possible through the Affordable Care Act.

The increase in ED visits, which is also largely attributable to the Affordable Care Act, "underscores an unabating demand for acute, unscheduled care," the authors note. "Our findings highlight the major role EDs play in the shift from inpatient to outpatient care — a role that will expand as ED visits and the proportion of hospitalizations originating in the ED continue to increase."

In the accompanying editorial, Mitchell H. Katz, MD, from NYC Health + Hospitals, New York City, suggests the major increase in ED visits signifies "an insatiable desire for immediate acute care." But for this increase, "[t]his drop in hospital admissions might be seen as a hopeful sign of decreasing costs in US health care," he writes. "Given the low overall hospital admission rate, many of these patients likely would have been more appropriate for office visits rather than ED. However, as we know, most physician offices are open Monday through Friday, 9 AM to 5 PM, and many are not able to schedule additional patients for acute care at the last minute. The result is a rational decision on the part of the patient to seek care in a place that is always open and has excellent immediate access to advance screening and specialty referral."

This decision by patients comes at a cost, Katz contends. "Ultimately this decision is likely to result in long waits for the patients, higher expenses for systems and patients, and more unnecessary care," he writes. "The growing lack of access to timely primary care in the United States has many ramifications; increased ED visits, identified in this study, may be another one."

There may also be hidden costs associated with declining admissions through the ED, according to the study authors. "Further research is needed to examine unintended consequences of reduced ED admissions, such as morbidity, mortality, readmissions, or ED revisit," they write.

The authors of the study and the editorial have disclosed no relevant financial relationships.

JAMA Intern Med. Published Online: October 15, 2018. Abstract, Editorial

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