Predictors of Regional Variations in Hospitalizations Following Emergency Department Visits for Atrial Fibrillation

Abstract

The emergency department (ED) is often where atrial fibrillation (AF) is first detected, acutely treated and affected patients dispositioned. We used the Nationwide Emergency Department Sample (NEDS) to estimate the percentage of visits resulting in hospitalization and investigate associations between patient and hospital characteristics with hospitalization at the national and regional levels. We conducted a cross-sectional study of adults with AF listed as the primary ED diagnosis in the 2007–2009 NEDS. We performed multivariable logistic regression analyses investigating the associations between pre-specified patient and hospital characteristics with hospitalization. From 2007–2009, there were 1,320,123 weighted AF ED visits, with 69% hospitalized nationally. Mean regional hospitalization proportions were: Northeast (74%), Midwest (68%), South (74%) and West (57%). The highest odds ratios for predicting hospitalization were heart failure (3.85, 95% CI 3.66 to 4.04), chronic obstructive pulmonary disease (2.47, 95% CI 2.34 to 2.61), and coronary artery disease (1.65, 95% CI 1.58 to 1.73). After adjusting for age, privately insured (0.77, 95% CI 0.73 to 0.81) and self-pay (0.77 95% CI 0.66 to 0.90) patients had lower odds when compared to Medicare recipients, whereas Medicaid (1.21, 95% CI 1.11 to 1.32) patients tended to have higher odds. Patients living in low-income zip codes (1.18, 95% CI 1.12 to 1.25) and individuals treated at large metropolitan hospitals (1.75, 95% CI 1.59, 1.93) had higher odds. In conclusion, our analysis showed considerable regional variation in the management of ED AF patients and in associations between patient socioeconomic and hospital characteristics with ED disposition; adapting best practices from among this variation in management could reduce hospitalizations and healthcare expenses.

Emergency Department Visits for Atrial Fibrillation in the United States: Trends in Admission Rates and Economic Burden From 2007 to 2014

“…The clinical characteristics described in this study were consistent with prior reports on ED visits for AF in the United States,9, 16, 19 as were the admission rates of up to 70% before 2011 9, 19, 20, 21. Despite the significant reduction in AF hospitalization rates in the latter half of the study period, 2 important trends persist.…”

Validation of the Risk Estimator Decision Aid for Atrial Fibrillation (RED-AF) for Predicting 30-Day Adverse Events in Emergency Department Patients With Atrial Fibrillation

“…The ability to achieve adequate rate control at 2 hours following initiation of ED treatment remains an important predictor. Given the preference of clinicians in the United States for rate control treatment in acute AF, [10, 27, 28] this is an important and sensible factor for risk stratifying patients within 2 hours. For example, a 45 year old male with lone AF who is adequately rate controlled within the first hour of ED management has a predicted probability an adverse event within 30 days of <5% and may be an excellent candidate for discharge and outpatient management.…”

“…[10, 28] These hospitalization frequencies are in stark contrast to the ED disposition practices in Canada, Europe and Australia where less than a third of patients are hospitalized. [21, 27, 29, 30] There continues to be considerable United States regional variation in hospitalization practices for ED patients with AF.…”

“…[10, 11] The costs of AF hospitalization in the United States are expected to rise by 55% in 2020 compared to 2010. [12] The mean hospital length of stay (LOS) for AF has remained unchanged at 3 days since 2000.…”

Emergency Department Management of Atrial Fibrillation and Flutter and Patient Quality of Life at One Month Postvisit

“…4,5 Management of ED patients with atrial fibrillation or flutter varies considerably; hospital admission rates are erratic across settings. 4,[6][7][8] Recent evidence suggests that aggressive protocols of ED cardioversion (pharmacologic or electrical) in patients with recent-onset paroxysmal atrial fibrillation or flutter are both safe and feasible. [9][10][11] Uptake of these protocols in clinical practice, as opposed to the traditional approach of exclusive rate control and stroke prevention, has been variable.…”