Do Return ED Visits Signal Lower Quality of Care?

This week, I’m revisiting a blog post from the summer that discusses whether or not return visits to the ED are an appropriate metric to consider when measuring quality of care. While one may think that return visits to the ED are a good indicator of hospital performance, a recent study from the Journal of the American Medical Association offers evidence to the contrary. 

When a patient makes a return visit to the emergency department, you may draw the conclusion that quality of care the first time wasn’t great. But a study recently published in the Journal of the American Medical Association offers data that may contend otherwise.

The study’s authors acknowledge that return visits to the ED “are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care.” So they set out to find whether or not these return visits, which led to in-patient admission, were evidence of a lower quality of care from the ED that initially treated the patient. The pervading question being, if a patient is ultimately admitted to the hospital, shouldn’t it occur during their first visit to the ED and not the second or third?

Researchers looked at in-hospital mortality, intensive care unit admission, length of stay, and inpatient costs to determine whether a patient returning to the ED was a reliable measure of quality of care within that ED. The results were surprising.

“Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay,” researchers concluded. “These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.”

Let’s look closely at the numbers. Patients discharged from an ED and subsequently admitted to the hospital upon a return visit experienced:

  • An in-hospital mortality rate of 1.85 percent vs. 2.48 percent for those patients admitted during their initial visit to the ED.
  • An ICU admission rate of nearly 6 percent less (23.3 percent vs 29 percent).
  • The cost of care for these patients was also less ($10,169 vs. $10,799), even though their length of stay was slightly higher (5.16 days vs. 4.97 days).

And for those patients admitted to the hospital within 14 and 30 days of their ED visit? Similar outcomes were experienced. 

But what about those patients readmitted to the hospital after hospital discharge and a return visit to the ED?

“In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit,” researchers found.

What do you think? Are return visits to the ED an adequate measure of quality of care? Please comment below, or feel free to drop me a line.

SOURCES:

The Journal of the American Medical Association: “In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department”