Hospital variation in risk-standardized hospital admission rates from US EDs among adults

Capp, Roberta; Ross, Joseph S.; Fox, Justin P.; Wang, Yongfei; Desai, Mayur M.; Venkatesh, Arjun K.; Krumholz, Harlan M.

doi:10.1016/j.ajem.2014.03.033

Cited by 26 publications

(34 citation statements)

References 23 publications

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“…This will have contributed to the modest discrimination of our models and could have led to some of the unexplained variation between hospitals in their outcome rates. Other studies already mentioned have shown notable influences of hospital factors on ED use and readmission rates, [71][72][73] so residual confounding is unlikely to explain all the between-hospital differences in our study.…”

Section: Discussion Of Methods and Findingsmentioning

confidence: 61%

See 1 more Smart Citation

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: Discussion Of Methods and Findingsmentioning

confidence: 61%

“…71 Another US study, from three hospitals, assessed the variation in rates of admission from the ED by individual physician. Among the 89 attending emergency physicians, admission rates varied from 21% to 49%, similar to previous Canadian studies.…”

Section: Discussion Of Methods and Findingsmentioning

confidence: 99%

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

View full text Add to dashboard Cite

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“…For example, Pines et al have shown that ED facility admission rates are higher in communities with fewer primary care physicians per capita and are influenced by the prevailing county level admission rates . Capp et al showed persistent variation in admission rates across hospitals, despite adjusting for clinical criteria such as vital signs, chief complaints, and severity of illness …”

Section: Discussionmentioning

confidence: 99%

Variation in readmission rates by emergency departments and emergency department providers caring for patients after discharge

Singh

Lin

Nattinger

et al. 2015

Journal of Hospital Medicine

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BACKGROUND The role of the emergency department (ED) provider and ED facility in readmissions of recently discharged patients who visit the ED has not been studied. OBJECTIVE To determine the variation in readmission rates by ED facility and ED providers caring for patients after discharge. DESIGN Retrospective cohort study using multilevel, multi-variable models of 100% Texas Medicare claims data from the years 2007 to 2011. SETTING Texas acute-care hospitals and ED facilities. PATIENTS Medicare beneficiaries who visited an ED within 30 days of discharge from a hospital. INTERVENTION None. MEASUREMENT Readmission after an ED visit within 30 days of discharge from an initial hospitalization defined as a hospitalization starting the day of or the day following the ED visit. RESULTS The mean readmission rate following an ED visit was 52.67%. In 2-level models, 14.2% of ED providers readmitted significantly more patients (mean readmission rate of 67.2%) than the mean; 14.7% of ED providers readmitted significantly fewer patients (mean readmission rate of 36.8%) than the mean. After accounting for the ED facility in 3-level models, the variance for the ED providers decreased 65% from 0.2532 to 0.0893. CONCLUSIONS The risk of readmission varies by ED provider caring for patients after discharge. A large part of this variation is explained by the ED facility in which the ED providers practice. Thus, ED provider practices patterns and ED facility systems of care may be a target for interventions to reduce readmissions.

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“…The primary outcome was hospital admission, either from the ED or admitted to an observation unit with subsequent hospital admission, defined as the ED risk‐standardized hospital admission rate (ED RSHAR) . This methodology allows for risk adjustment of case mix (ie, disease severity) for each hospital's ED admission rates and has been previously described in the evaluation of varying ED hospital admission rates using the same dataset . To evaluate which hospitals had observation units, we used the following hospital survey question: “Does your ED have an observation or clinical decision unit?”…”

Section: Methodsmentioning

confidence: 99%

“…ED hospitalization rates were risk standardized for each hospital to account for each hospital's case mix and hospital factors such as socioeconomic status, clinical severity, and hospital characteristics. This methodology and dataset use have been previously described in detail …”

Section: Methodsmentioning

confidence: 99%

The impact of emergency department observation units on United States emergency department admission rates

Capp

Sun

Boatright

et al. 2015

Journal of Hospital Medicine

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OBJECTIVE: Prior studies suggesting that the presence of emergency department (ED) observation units decrease overall ED hospital admissions have been either singlecenter studies or based on model simulations. The objective of this preliminary national study is to determine if the presence of ED observation units is associated with hospitals having lower ED admission rates. METHODS:We conducted a retrospective cross-sectional analysis using the 2010 National Hospital Ambulatory Care Survey and estimated ED risk-standardized hospital admission rates (RSHAR) for each center. The following were excluded from the study: ages <18 years, leaving prior to completion of ED visit, died in the ED, transferred to another facility, and missing disposition. Hospitals with less than 30 ED visits or unknown observation unit status were also excluded. We used linear regression analysis to determine the association between ED RSHAR and presence of observation units.RESULTS: There were 24,232 ED visits in 315 hospitals in the United States. Of these, 82 (20.6%) hospitals had an ED observation unit. The average ED risk-standardized hospital admission rates for hospitals with observation units and without hospital observation units were 13.7% (95% confidence interval [CI]: 11.3-16.0) and 16.0% (95% CI: 14.1-17.7), respectively. The difference of 2.3% was not statistically significant. CONCLUSIONS:In this preliminary study, we did not find an association between the presence of observation units and ED hospital admission rates. Further studies with larger sample sizes should be performed to further evaluate the impact of ED observation units on ED hospital admission rates. Journal of Hospital Medicine 2015;10:738-742. V C 2015 Society of Hospital Medicine Today more than one-third of emergency departments (EDs) in the United States have affiliated observation units, where patients can stay 24 to 48 hours without being admitted to the hospital. 1 Observation units experienced significant growth in the United States from 2005 to 2007, secondary to policy changes involving the Centers for Medicare and Medicaid Services (CMS), which expanded reimbursement for observation services to include any clinical condition. Furthermore, CMS implemented the Recovery Audit Contractor process, which was able to fine providers and facilities for inappropriate claims, with the principle method for charge recovery being "inappropriate" charges for short inpatient stays.ED observation units (EDOUs) vary in the number of beds, but are often located adjacent to the emergency department. 2 It is estimated that EDOUs have the capacity for caring for 5% to 10% of any given ED volume. 2 Almost half of EDOUs are protocol driven, allowing these units to discharge up to 80% of all patients within 24 hours. 1,2 Some studies have suggested that EDOUs are associated with a decrease in overall hospitalization rates, leading to cost savings. 1 However, these studies were limited by their single-center design or simulated in nature. In addition, other studies show tha...

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Hospital variation in risk-standardized hospital admission rates from US EDs among adults

Cited by 26 publications

References 23 publications

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

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

Variation in readmission rates by emergency departments and emergency department providers caring for patients after discharge

The impact of emergency department observation units on United States emergency department admission rates

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