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Breaking News: Bouncebacks Prove to be Poor Measure of ED Quality

Sorelle, Ruth MPH

doi: 10.1097/01.EEM.0000488817.02695.0b
Breaking News
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Short-term return visits to the emergency department — so-called bouncebacks — may not be the quality markers that health economists and politicians think they are, according to emergency medicine researchers in the Journal of the American Medical Association. (2016;315[7]:663; http://bit.ly/1ZASybu.)

Return visits are a hot topic, supported since the 1970s by an American College of Emergency Physicians' 72-hour revisit metric, though no reason existed to support the notion that 72-hour revisits were important, said Amber K. Sabbatini, MD, MPH, the Patient-Centered Outcomes Scholar in emergency medicine at the University of Washington in Seattle.

“There is now increasing attention to quality measurements,” she said. “If you look at most measurements hospitals have to report on, most are not emergency department-specific. There is now attention in the specialty to the issue of designing measures that reflect the quality of emergency department care.”

The researchers used the large Healthcare Cost and Utilization Project database funded by the Agency for Healthcare Research and Quality to analyze retrospectively adult emergency department visits to acute care hospitals in Florida and New York in 2013. (http://1.usa.gov/MAkCMe.) They identified patients with index ED visits and those who had return visits to the emergency department within seven, 14, and 30 days. They compared in-hospital mortality, admission to the intensive care unit, length of stay, and inpatient costs in each group.

They found that 1.76 million patients of the more than nine million index ED visits to the 424 hospitals were admitted to the hospital during that first emergency department visit. A total of 149,214 (8.5%) of them revisited the ED within seven days of that first visit, 228,370 (13%) came back within 14 days of the first visit, and 349,335 (19.9%) returned within 30 days.

A total of 76,151 (51%) of those in the seven-day group, 122,040 (53.4%) in the 14-day group, and 190,768 (54.6%) in the 30-day group were readmitted. Of the 7.3 million patients discharged after the index ED visit, in contrast, 598,404 (8.2%) returned to the emergency department for a visit within seven days, 839,386 (11.5%) revisited within 14 days, and 1.2 million (16.6%) came back within 30 days. A total of 86,012 (14.4%) in the seven-day group, 121,587 (14.5%) in the 14-day group, and 173,279 (14.4%) in the 30-day group were readmitted.

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The 86,012 patients discharged from the emergency department and admitted to the hospital during a return visit within seven days had significantly lower rates of mortality in the hospital (1.85%) compared with the 1.76 million patients admitted during the index visit without a return ED visit (2.5%). These patients also had lower rates of ICU admission than patients admitted to the hospital during the first visit (23.3% vs. 29%), and their costs were lower as well ($10,169 vs. $10,799). Lengths of stay, however, were longer (5.16 days vs. 4.97 days).

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Poor Measure of Care

The authors noted that outcomes were similar for patients who returned to the ED within 14 and 30 days of the index visit, suggesting that admissions associated with ED revisits “may not adequately capture deficits in the quality of care delivered during an ED visit.”

“Revisits are not a measure of quality of care,” Dr. Sabbatini said. “We would consider it high-quality care to discharge a patient who does not quite meet admission criteria and avoid exposing him or her to the inpatient risks, but we say, ‘Come back to us if you are getting worse. That would be good quality of care.’”

She noted that those patients admitted on a revisit were a “less sick cohort. Part of that makes sense from the perspective that those admitted at the index visit are older, more comorbid, and fragile. We are testing outpatient management on patients who might do well. They are often readmitted because they present again,” Dr. Sabbatini said. “You ideally want a measure where you can capture patients who do more poorly.”

She said she and her colleagues initially thought patients who bounced back would do more poorly than the average admission.

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Mistakes in the Data

James G. Adams, MD, a senior vice president and CMO of Northwestern Medicine and a professor and the chair of emergency medicine at Northwestern University Feinberg School of Medicine, noted in an accompanying JAMA editorial that “return visits to the ED have been of persistent concern because of the perception that patients who experience ED revisits are at high risk for poor health outcomes or may have been misdiagnosed or incorrectly or inadequately treated during their initial ED visit. The important question in the era of electronically enabled reporting is whether the return visit rate can be used as a marker of ED quality. The simple answer, long suspected and now clearly proven in the report by Sabbatini and colleagues ... is no.” (JAMA 2016;315[7]:659; http://bit.ly/1TPl9rW.)

“Nationally, we are looking for good markers of quality in every specialty,” said Dr. Adams. That search is particularly appealing in emergency medicine with high volumes of patients and the critical problems they often face. “If we make a mistake in the ED, those patients are going to come back. Clearly, the mistakes are in [the data] somewhere, so is a lot of other stuff. We can't dissect out that easily.”

Emergency physicians at the John H. Stroger Hospital of Cook County see strokes, heart attacks, and kidney failure driven by untreated blood pressure, Dr. Adams said. Some patients cannot get the care needed to control hypertension. Add them to the patients who have chronic disease problems, and mental health and addiction issues, and it is a difficult population, but the hospital set up a follow-up clinic to deal with patients who keep coming back.

“We have a special internist; we have a social worker connected with psychiatry in that clinic,” he said. “We tell the patients to go to that clinic the next day or week and get things sorted out. Then they get transitioned into mental health clinics and more intensive primary care. You can't blame the patient whose life is a wreck.”

Part of the answer might be to measure segments of the population and solve their problems. “Lumping them together doesn't tell you anything,” said Dr. Adams.

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