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

Abstract

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.

Should Emergency Department Attendances be Used With or Instead of Readmission Rates as a Performance Metric?

“…The small amount of the total variation in readmission attributable to hospitals, as shown by ICCs, is consistent with previous studies of both readmission 34 and mortality. 35 In addition, Thompson et al 36 concluded that most of the variation for both COPD and HF risk-standardized readmission rates was due to random statistical variation.…”

Variation Among Primary Care Physicians in 30-Day Readmissions

“…Our finding of minimal variation in readmission rates by PCP should be taken in the context of our previous research that showed significant variation in risk for readmission by ED physician (10). At the hospital level, overall admission rates are a major determinant of hospital readmission rates (23).…”

“…Early follow-up after hospital discharge is sometimes associated with lower readmission rates (8, 9). We previously reported that risk for readmission varies moderately but significantly by ED physician, identifying an opportunity for improvement (10). However, whether PCP care influences readmissions is uncertain, although CMS has implemented a policy incentivizing PCPs to reduce readmissions (11).…”

Hospital Characteristics Associated With Postdischarge Hospital Readmission, Observation, and Emergency Department Utilization

“…Variation in performance according to hospital characteristics has been separately described for readmission outcomes, observation care and ED visits. 4,[8][9][10][11][12] For example, large hospitals, teaching hospitals and urban hospitals tend to have slightly higher readmission rates. [13][14][15][16] Whether the types of hospitals with low readmission rates also have low overall post-discharge utilization, however, is uncertain.…”