Revisits After Emergency Department Discharge for Conditions With High Disposition-Decision Variability at Hospitals With High and Low Discharge Rates

Avi Baehr, MD; Angela J. Fought, MS; Renee Y. Hsia, MD, MSc; Jennifer L. Wiler, MD, MBA; Adit A. Ginde, MD, MPH

Disclosures

Western J Emerg Med. 2022;23(4):564-569. 

In This Article

Abstract and Introduction

Abstract

Introduction: The first proposed emergency care alternative payment model seeks to reduce avoidable admissions from the emergency department (ED), but this initiative may increase risk of adverse events after discharge. Our study objective was to describe variation in ED discharge rates and determine whether higher discharge rates were associated with more ED revisits.

Methods: Using all-payer inpatient and ED administrative data from the California Office of Statewide Health Planning and Development (OSHPD) 2017 database, we performed a retrospective cohort study of hospital-level ED discharge rates and ED revisits using conditions that have been previously described as having variability in discharge rates: abdominal pain; altered mental status; chest pain; chronic obstructive pulmonary disease exacerbation; skin and soft tissue infection; syncope; and urinary tract infection. We categorized hospitals into quartiles for each condition based on a covariate-adjusted discharge rate and compared the rate of ED revisits between hospitals in the highest and lowest quartiles.

Results: We found a greater than 10% difference in the between-quartile median adjusted discharge rate for each condition except for abdominal pain. There was no significant association between adjusted discharge rates and ED revisits. Altered mental status had the highest revisit rate, at 34% for hospitals in the quartile with the lowest and 30% in hospitals with the highest adjusted discharge rate, although this was not statistically significant. Syncope had the lowest rate of revisits at 16% for hospitals in both the lowest and highest adjusted discharge rate quartiles.

Conclusion: Our findings suggest that there may be opportunity to increase ED discharges for certain conditions without resulting in higher rates of ED revisits, which may be a surrogate for adverse events after discharge.

Introduction

The emergency physician's decision to admit a patient is among the most expensive and consequential decisions in healthcare. In 2017, hospital expenditures accounted for nearly a third of the United States' $3.5 trillion in healthcare spending,[1] with the majority of these admissions originating from the emergency department (ED).[2] While critical illness and minor injury carry straightforward disposition decisions, other common conditions have marked interhospital variability in discharge rates.[3,4] Studies of select populations[5–7] have shown a significant burden of potentially avoidable admissions. Paired with the demonstrated interhospital variability in admission rates, this suggests an opportunity to improve healthcare value by decreasing unnecessary costs associated with avoidable admissions.[8]

To address this opportunity, the American College of Emergency Physicians has proposed an alternative payment model, the Acute Unscheduled Care Model (AUCM), which targets reducing avoidable admissions for conditions with high variability in hospital-level admission rates.[9] This model has been endorsed by the US Secretary for Health and Human Services and is under consideration for implementation by the Center for Medicare & Medicaid Innovation as well as private payers. If adopted, this model would be the first emergency care-based alternative payment model and stands to significantly alter the landscape of value-based payments for emergency care.[9]

Reducing costs is only one component of the value equation, and the AUCM pairs the incentive to reduce admissions with an emphasis on care coordination and adverse event reduction after ED discharge.[9] Little is known, however, about how higher ED discharge rates are associated with post-ED discharge adverse events. One study in Medicare patients found that hospitals with higher ED discharge rates had a threefold increase in mortality rates after ED discharge,[10] while another study of Medicare patients with syncope did not find an association between ED discharge rates and post-discharge adverse events.[3] In addition to suggesting different trends in the association between ED discharge rates and adverse event rates, these studies were limited only to the Medicare population, and to our knowledge this topic has not yet been explored in a more general ED population.

Using conditions that had been previously identified as having high variability in discharge rates,[3,4] our study objective was to describe variation in ED discharge rates and determine whether higher discharge rates were associated with higher rates of ED revisits.

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