Readmissions may be more than inpatient stays

By  |  December 8, 2013 | 

“The use of hospital readmissions as a lone metric for post-discharge health care quality may be incomplete without considering the role of the ED.”

Do you agree?

I would probably say yes, providing patients we include in the numerator return to the ED with an issue related to their index trip—be it clinical or ancillary.  We may not like to hear those words, but a return visit, regardless of admission, likely connotes a transition failure.

Earlier in the year, JAMA examined HCUP data from three states (CA, FL, and NE) to determine the degree to which ED visits and hospital readmissions contribute to overall use of acute care services within 30 days of discharge from acute care hospitals.  The graph below illustrates the percent of patients returning to the hospital after discharge:

ER use after admit


Approximately 40% of folks making round trips come back to ERs only.  By virtue of mass alone, all recidivists likely deserve closer examination.  With the rise in observation units, I would surmise we need to double the effort.

The authors caution though:

However, it is important to note that ED use after discharge is not synonymous with a lapse in quality. In the design of interventions to reduce high rates of acute care use after hospital discharge, these descriptive results should be used to inform future research and to identify the underlying, modifiable patient factors and system failures that increase risk.

To add to above, this month’s Health Affairs also features a helpful study on patients returning to emergency rooms in less than thirty days post discharge.  However, they examined facilities located proximal to, but different from the location of the first stay.

The investigators tapped an HIE encompassing ten NYC hospitals.  They searched for site specific and HIE-wide bound patients who presented back to institutions for acute care, but not requiring stays.  The numbers impressed me:



Wide as the variation might be, hospitals miss 20% of ER returns if they look at their own data.  Most would likely conclude based on these findings, we need better tools to examine ER activity.

I would be willing to bet most catchment areas parallel the findings here, and all committees assigned to sniffing out 30-day returns need to take heed: a lot goes unnoticed and the problem, like a small weed shooting through the pavement cracks, has deeper roots than we suspect.

I highlight the studies as a premonitory warning.  CMS will note above, and at some point, hospitals will take ownership of patients returning to non-ambulatory sites for post-acute care.  If you believe responsibility for readmissions falls on our backs (assuming current measurements improve), the ER visit has its place in the regulatory framework of CMS.  In the end, substandard ER and inpatient episodes sit on the continuum of the same disorder, with similar root causes, but only differing in degree.

BONUS: If you have an interest in the observation status dilemma, the Alliance for Health Reform held a briefing last week.  Watch here.

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About the Author: Bradley Flansbaum

Bradley Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.


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