Efforts to Reduce Hospital Readmission and Improve Care Transition Should Consider ED Visits

Initiatives aimed at reducing hospital readmissions miss more than 50 percent of all returns to the acute level of care after inpatient hospital discharge when they exclude emergency department (ED) visits, according to a study published in Annals of Emergency Medicine, April 2013. “By limiting the focus of hospital readmissions measurement to only inpatient-to-inpatient events and omitting ED visits shortly after hospital discharge, researchers and policy makers may be missing a substantial source of return-to-acute health care use that is managed solely by the ED,” the study stated. “Emergency physicians are increasingly filling voids left by difficult or unsuccessful transitions of care,”  said lead study author Kristin Rising, MD, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.  “Including emergency department visits will give a more accurate assessment of where care transitions can be improved and how recurrent hospital utilization can potentially be avoided.”

Medicare’s Hospital Readmissions Reduction Program  

Section 3025 of the Patient Protection Affordable Care Act added §1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to inpatient prospective payment system (IPPS)  hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. CMS defined readmission as an admission to an IPPS hospital within 30 days of a discharge from the same or another IPPS hospital. According to CMS, readmission rates are important markers of quality of care, particularly of the care of a patient in transition from an acute care setting to a nonacute care setting, and improving readmissions can positively influence patient outcomes and the cost of care. (see Final rule, 76 FR 51476, August 18, 2011.).

Physicians, nurses, hospitals, employers, patients and their advocates, and the federal and state governments have joined together to form the Partnership for Patients, with three operational partners that include federal agencies, Hospital Engagement Networks, and private-public partners. One goal of the Partnership for Patients is improving care transitions. By the end of 2013, decreasing preventable complications during a transition from one care setting to another could reduce all hospital readmissions by 20 percent compared to 2010. Achieving this goal would mean more than 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge., according to the Partnership.

The Study

The researchers examined 15,519 inpatient discharge records from an urban academic medical center from January 1 through May 31, 2010. Researchers used data spanning a six month period of hospital activity to estimate their primary outcome. Patients linked to each discharge were followed from the discharge date to determine whether they had at least one return to the hospital in 30 days. Nearly one-quarter (23.8 percent) of these discharges resulted in at least one emergency department visit within the subsequent 30 days although over half (54 percent) of the emergency visits did not lead to hospital readmission, according to the study. The primary discharge diagnosis with the highest absolute number of discharges linked to an ED visit within 30 days was nonspecific chest pain; however, nonhypertensive congestive heart failure was the diagnosis with the highest rate of return ED visits (31.8 percent of discharges) and the highest rate of 30-day readmissions (82.6 percent).

Researchers concluded that inclusion of ED visits as a return to the acute care setting may enhance providers’ efforts to identify opportunities to improve care transitions and intervene in a cycle of frequent hospitalizations. In addition, with the implementation of 30-day readmission measures, emergency physicians will be under increasing pressure to find alternatives to admitting patients. Tracking the frequency with which patients are returning to the ED after hospital discharge and better defining the needs with which they present may help emergency physicians play a vital role in breaking the readmission cycle.

Other Studies

According to an analysis of 2005-2008 data from the National Hospital Ambulatory Medical Care Survey reported in 2011, rates of hospital readmission from the emergency department of patients who were recently hospitalized are on the rise, Miriam E. Tucker reported in the ACEP News. The data showed that patients who return to the ED within seven  days of hospitalization have both relatively high and increasing rates of readmission. Policies and programs aimed at reducing hospital readmissions should consider the role of the ED in determining the disposition of recently hospitalized patients,” said  Dr. Zachary F. Meisel of the University of Pennsylvania, Philadelphia . In another study, reported in the Journal of the American Medical Association (JAMA) in January 2013, the researchers found that in three states, ED visits within 30 days were common among adults and accounted for 39.8 percent of postdischarge hospital-based acute care visits. The researchers concluded that improving care transitions should focus not only on decreasing readmissions but also on ED visits.