162 EMF Characterizing Hospital-Level Variation in Emergency Department Visitation After Hospital Discharge for Medicare Beneficiaries

Venkatesh, Arjun K.; Wang, C.; Ross, Joseph S.; Suter, Lisa G.; Vellanky, Smitha; Grady, Jacqueline N.; Atlaf, F.K.; Han, Ling; Bernheim, Susannah M.

doi:10.1016/j.annemergmed.2015.07.194

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“…94 Finally, ED visits following an index inpatient spell are increasingly recognised as an important issue, irrespective of whether or not they result in hospitalisation as an inpatient. 64,65 They can be for another deterioration of the HF or COPD or for one or more of the patient's various comorbidities, and can of course be for a totally new medical or surgical problem unrelated to either. They can also occur for a wide range of other reasons, for example problems with discharge medication, patients' lack of confidence in their ability to self-manage, health-care access and fragmented care transitions.…”

Section: Implications For Practice and Translation Of Findingsmentioning

confidence: 99%

“…A total of 22.5% of Medicare beneficiaries came to the ED within 30 days after hospitalisation for HF, with congestive HF the most common reason for attendance, although accounting for only 11% of these visits. 65 The same study noted wide hospital-level variation in post-discharge ED visit rates for each condition: acute myocardial infarction (AMI) (median 8.3%, 5th to 95th percentile 2.8% to 14.3%), HF (median 7.3%, 5th to 95th percentile 3.0% to 13.3%) and pneumonia (median 7.1%, 5th to 95th percentile 2.4% to 13.2%). The authors concluded that 'policymakers and researchers should further study post-discharge ED visits as measures of health-care access and care transitions in the vulnerable Medicare population.'…”

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Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study

Bottle

Honeyford

Chowdhury

et al. 2018

Health Serv Deliv Res

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BackgroundHeart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplanned hospital activity, but our understanding of what drives this is incomplete.ObjectivesTo model patient, primary care and hospital factors associated with readmission and mortality for patients with HF and COPD, to assess the statistical performance of post-discharge emergency department (ED) attendance compared with readmission metrics and to compare all the results for the two conditions.DesignObservational study.SettingEnglish NHS.ParticipantsAll patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.InterventionsNone.Main outcome measuresOne-year mortality and 30-day emergency readmission following the patient’s first unplanned admission (‘index admission’) for HF or COPD.Data sourcesPatient-level data from Hospital Episodes Statistics were combined with publicly available practice- and hospital-level data on performance, patient and staff experience and rehabilitation programme website information.ResultsOne-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were 19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factors predicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long) index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS and comorbidities also predicted readmission. Of the practice and hospital factors we considered, only more doctors per 10 beds [odds ratio (OR) 0.95 per doctor;p < 0.001] was significant for both cohorts for mortality, with staff recommending to friends and family (OR 0.80 per unit increase;p < 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP;p = 0.004) important for COPD. For readmission, only hospital size [OR per 100 beds = 2.16, 95% confidence interval (CI) 1.34 to 3.48 for HF, and 2.27, 95% CI 1.40 to 3.66 for COPD] and doctors per 10 beds (OR 0.98;p < 0.001) were significantly associated. Some factors, such as comorbidities, varied in importance depending on the readmission diagnosis. ED visits were common after the index discharge, with 75% resulting in admission. Many predictors of admission at this visit were as for readmission minus comorbidities and plus attendance outside the day shift and numbers of admissions that hour. Hospital-level rates for ED attendance varied much more than those for readmission, but the omega statistics favoured them as a performance indicator.LimitationsData lacked direct information on disease severity and ED attendance reasons; NHS surveys were not specific to HF or COPD patients; and some data sets were aggregated.ConclusionsFollowing an index admission for HF or COPD, older age, prior missed outpatient appointments, LOS and many comorbidities predict both mortality and readmission. Of the aggregated practice and hospital information, only doctors per bed and numbers of hospital beds were strongly associated with either outcome (both negatively). The 30-day ED visits and diagnosis-specific readmission rates seem to be useful performance indicators.Future workHospital variations in ED visits could be investigated using existing data despite coding limitations. Primary care management could be explored using individual-level linked databases.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Implications For Practice and Translation Of Findingsmentioning

confidence: 99%

mentioning

confidence: 99%