Early death after discharge from emergency departments: analysis of national US insurance claims data

Abstract

ObjectiveTo measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients.DesignRetrospective cohort study.SettingClaims data from the US Medicare program, covering visits to an emergency department, 2007-12.ParticipantsNationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded.Main outcome measureDeath within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.ResultsAmong discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)—3.4 times higher than hospitals in the highest fifth (0.08%)—despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7).ConclusionsEvery year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.

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

“…Alternatively, it could reflect temporarily lower inpatient availability, as many hospitals struggle to discharge their patients before noon, or differences in staff decision-making. Obermeyer et al 91 looked at deaths in people sent home from the ED, a patient safety issue, and found a 93 had set out with that aim. Shortness of breath is a frequent complaint in patients presenting to EDs, but only a small proportion of them will have HF or COPD.…”

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“…Journals that run series about overuse, such as The BMJ and JAMA Internal Medicine , routinely publish studies of beneficial interventions or studies showing that more care is better (such as The BMJ article showing higher mortality for patients discharged from emergency departments with lower admission rates18). …”

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“…What we can learn from Medicare data on early deaths after emergency department discharge Sukayna Z. Alfaraj 1,2 , Jesse M. Pines 1 estimated to make up 31-57% of all ED visits (7). For example, a common ED complaint is chest pain.…”

“…The primarily finding was that 0.12%-or 12 in 10,000 people-had died, primarily from atherosclerotic heart disease, myocardial infarction, and chronic obstructive pulmonary disease. About 2% died from narcotic overdose, primarily after visits for musculoskeletal problems (1).…”