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The American Journal of Managed Care March 2018
False-Positive Mammography and Its Association With Health Service Use
Christine M. Gunn, PhD; Barbara Bokhour, PhD; Tracy A. Battaglia, MD, MPH; Rebecca A. Silliman, MD, PhD; and Amresh Hanchate, PhD
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Zirui Song, MD, PhD; Amol S. Navathe, MD, PhD; Ezekiel J. Emanuel, MD, PhD; and Kevin G. Volpp, MD, PhD
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Patients Discharged From the Emergency Department After Referral for Hospitalist Admission
Christopher A. Caulfield, MD; John Stephens, MD; Zarina Sharalaya, MD; Jeffrey P. Laux, PhD; Carlton Moore, MD, MS; Daniel E. Jonas, MD, MPH; and Edmund A. Liles Jr, MD
Ambulatory Care–Sensitive Emergency Visits Among Patients With Medical Home Access
Dina Hafez, MD; Laurence F. McMahon Jr, MD, MPH; Linda Balogh, MD; Floyd John Brinley III, MD; John Crump, MD; Mark Ealovega, MD; Audrey Fan, MD; Yeong Kwok, MD; Kristen Krieger, MD; Thomas O'Connor, MD; Elisa Ostafin, MD; Heidi Reichert, MA; and Jennifer Meddings, MD, MSc
Improving Quality of Care in Oncology Through Healthcare Payment Reform
Lonnie Wen, RPh, PhD; Christine Divers, PhD; Melissa Lingohr-Smith, PhD; Jay Lin, PhD, MBA; and Scott Ramsey, MD, PhD
Assessing Medical Home Mechanisms: Certification, Asthma Education, and Outcomes
Nathan D. Shippee, PhD; Michael Finch, PhD; and Douglas R. Wholey, PhD
Patient-Reported Denials, Appeals, and Complaints: Associations With Overall Plan Ratings
Denise D. Quigley, PhD; Amelia M. Haviland, PhD; Jacob W. Dembosky, MPM; David J. Klein, MS; and Marc N. Elliott, PhD

Patients Discharged From the Emergency Department After Referral for Hospitalist Admission

Christopher A. Caulfield, MD; John Stephens, MD; Zarina Sharalaya, MD; Jeffrey P. Laux, PhD; Carlton Moore, MD, MS; Daniel E. Jonas, MD, MPH; and Edmund A. Liles Jr, MD
Hospitalization is costly and associated with the potential for adverse medical events. Hospitalists are uniquely positioned to help avoid unnecessary emergency department admissions through consultation.
ABSTRACT

Objectives: To describe the characteristics and outcomes of patients discharged from the emergency department (ED) by hospitalist physicians.

Study Design: Retrospective cohort study at a tertiary academic medical center.

Methods: We used consultation Current Procedural Technology codes to identify patients discharged from the ED after referral for hospitalist admission from April 2011 to April 2014. We report patient demographics and primary diagnoses. Main outcome measures included return to the ED, hospitalization, or mortality, all within 30 days.

Results: There were 710 discharges from the ED for 670 patients referred for hospitalist admission; 21.7% returned to the ED, 12.3% were hospitalized, and 0.4% died within 30 days. Chest pain was the most common diagnosis (38.2%); 18.1% of these patients returned to the ED within 30 days. Patients with the following 3 diagnoses returned to the ED most frequently: sickle cell disease (82.4%), alcohol-related diagnoses (43.5%), and abdominal pain (35.7%). In multivariate analysis, abdominal pain (odds ratio [OR], 3.2; <.001) and alcohol dependence (OR, 3.1; = .003) increased the odds of ED revisits, whereas syncope (OR, 0.23; P = .049) reduced the odds. Chest pain reduced the odds of hospitalization (OR, 0.37; P = .005).

Conclusions: A majority of patients discharged from the ED after referral for hospitalist admission did not return to the ED within 30 days, and the 30-day hospitalization rate was low. Our data suggest that hospitalists can safely aid patients by reducing the costs and adverse outcomes associated with unnecessary hospitalization.

Am J Manag Care. 2018;24(3):152-156
Takeaway Points

Hospitalists are uniquely positioned to help avoid unnecessary admissions. Among 710 emergency department (ED) discharges for 670 patients referred for hospitalist admission:
  • Four of 5 patients did not return to the ED and 9 of 10 patients did not require hospitalization within 30 days.
  • Chest pain was the most common diagnosis.
  • Those with alcohol-related diagnoses, abdominal pain, and sickle cell disease with crisis were more likely to return to the ED, whereas those presenting with chest pain were less likely.
  • Those with Medicare and Medicaid were more likely to return to the ED compared with those who were privately insured.
There are approximately 136.3 million emergency department (ED) visits in the United States each year; 16.2 million of these visits result in a hospital admission.1 Hospitalization is expensive: The average cost per hospital stay in 2012 was $10,4002 and more than one-third of healthcare spending within the United States is attributable to hospital care.3 Hospitalization is also associated with potential harms. A 2013 study estimated that 7% of hospitalizations are associated with a “highly undesirable event.”4 Additionally, approximately 20% of hospitalized patients will experience an injury related to medical management within a month of discharge.5 Some authors argue that hospitalization itself has deleterious health consequences, an acquired transient condition of increased generalized health risk dubbed “posthospital syndrome.”6

Unnecessary hospitalizations, therefore, expose patients to unnecessary costs and risks. Hospitalist physicians are well positioned to evaluate the need for admission for patients referred from the ED. Recent efforts have focused on finding safer and more efficient ways of caring for patients who come to the hospital through the ED7,8 and improving collaboration between ED physicians and hospitalists.9 However, the characteristics and outcomes of patients discharged from the ED after referral for admission have not yet been explored. In this report, we describe the demographics, diagnoses, and healthcare outcomes of patients discharged from the ED after referral for hospital admission at an academic medical center.

METHODS

We conducted a retrospective cohort study at an 804-bed tertiary academic medical center, the University of North Carolina Hospitals. We received institutional review board approval for this study (UNC IRB #14-2559). The Division of Hospital Medicine at the University of North Carolina School of Medicine is responsible for approximately 25% of all patients admitted through the ED. Occasionally, ED patients referred for admission are evaluated by a hospitalist physician and deemed safe for discharge without hospitalization. The consulting hospitalist assumes responsibility for providing discharge instructions, documentation of a consult note, and any necessary follow-up arrangements and prescription medications.

Consults performed in the ED by hospital medicine physicians over the 3-year period between April 1, 2011, and April 1, 2014, were identified via Current Procedural Terminology consult codes 99241 through 99245 and 99281 through 99285. One investigator reviewed the medical record of each patient to ensure accuracy of the data. Patients were included if they were: 1) referred for admission to our hospital medicine group or general medical teaching service with a hospitalist attending and 2) were discharged from the ED after medical consultation. We excluded patients who were admitted to any hospital service after the index consultation.

We collected demographic data, including age, race, sex, and type of insurance. Primary and secondary diagnoses were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes assigned to the index consultation. All diagnoses were categorized into common or related diagnosis groups (eg, all ICD-9 codes related to chest pain).

The primary outcome measures were rates of return to the ED within 30 days, hospitalization within 30 days, and mortality within 30 days of an index consultation. Mortality data were verified for each patient by manual chart review and via search of the US Social Security Death Index, which contains mortality data through February 28, 2014, due to record availability and legislative ruling.10,11 Rates of ED returns, hospitalizations, and mortality within 30 days were calculated as percentages for all patients, as well as for the 6 most common diagnosis groupings. Unadjusted and adjusted analyses (using multivariate logistic regression) were used to describe demographic (age, gender, race/ethnicity, and insurance type) and clinical (diagnosis at index consult) predictors of return to the ED and hospitalization within 30 days after the index consult. Statistical calculations were performed using Stata/SE 13.1 (StataCorp; College Station, Texas).

RESULTS

Patient Characteristics

There were 710 patient encounters identified during the study period for 670 unique patients (eAppendix [available at ajmc.com]). The mean age was 52.1 years. More than half of the patients (61.0%) were white, and almost 30% were black. Approximately 75% of the patients had some form of insurance, with Medicare making up the largest single insurance type.

Diagnoses

There were 178 diagnoses. The most common diagnosis was unspecified chest pain (34.1%), followed by unspecified abdominal pain (9.0%). The 6 most common diagnosis groups, shown in Table 1, made up 68.2% of the total patient encounters analyzed. After categorization, chest pain was the largest diagnosis group (38.2%).

30-Day ED Revisit Rates

Of all patient encounters in the study, 21.7% returned to the ED within 30 days of the index consultation. For the patient encounters with chest pain, 18.1% returned to the ED within 30 days. There was large variability in the 30-day revisit rates based on diagnosis (Table 1). The 3 diagnosis groups that returned to the ED most frequently were sickle cell disease with crisis, alcohol-related diagnoses, and abdominal pain. These diagnoses made up 18.7% of the total cohort of patient encounters evaluated.

In adjusted analysis (Table 2), a diagnosis of abdominal pain (odds ratio [OR], 3.23; 95% CI, 1.75-5.94) or alcohol-related diagnoses (OR, 3.10; 95% CI, 1.49-6.45) increased the likelihood of return to the ED within 30 days. Syncope (OR, 0.23; 95% CI, 0.05-0.99) decreased that likelihood. Among insurance types, patients with Medicaid had the highest likelihood of returning to the ED within 30 days (OR, 4.54; 95% CI, 2.27-9.49). Patients with private insurance and other forms of healthcare coverage (ie, liability, TRICARE, worker’s compensation) were least likely.

30-Day Hospitalization Rates

We found that 12.3% of all patients were hospitalized within 30 days (Table 1). Of those who initially presented with chest pain, 6.3% were hospitalized within 30 days, including 1 (0.1%) who returned to the hospital with an ST-segment elevation myocardial infarction (STEMI); the patient was successfully treated and had an uncomplicated hospital course. In adjusted analysis (Table 2), patients with chest pain had a reduced likelihood of hospitalization (OR, 0.37; 95% CI, 0.19-0.74). Similar to the ED revisit results, the patients most frequently hospitalized within 30 days were initially diagnosed with sickle cell disease with crisis, alcohol-related diagnoses, and abdominal pain. In addition, patients with Medicaid had the highest likelihood of hospitalization among insurance types (OR, 3.94; 95% CI, 1.59-9.74).

Mortality Within 30 Days

Of all patients evaluated, 3 (0.4%) died within 30 days of an index consultation. Two of the patients were receiving hospice care, one with a diagnosis of terminal metastatic bladder cancer and the other with terminal metastatic prostate cancer. The third patient was diagnosed with pneumonia and ultimately found to have progressive renal cell carcinoma.

DISCUSSION

Our study found that the majority of patients discharged from the ED after referral for hospitalist admission did not have subsequent acute healthcare utilization, with 4 of 5 patients avoiding an ED return visit and 9 of 10 patients avoiding hospitalization within 30 days. These numbers were similar to our ED’s 30-day revisit rate, which was slightly less than 20% at the beginning of 2016, and our own hospital medicine group’s readmission rate, which was around 10% during the time period of our study. The 30-day ED revisit rate for our study was likely slightly higher than our ED’s 30-day revisit rate due to the higher proportion of patients with sickle cell disease and alcohol-related diagnoses that the ED asks our hospitalists to evaluate for admission. Mortality for this cohort, identified via manual record review for all patients and the US Social Security Death Index for the majority, was well below 1%. Given the known harms associated with hospitalization, these results suggest that hospitalist physicians are able to safely benefit patients and the healthcare system by identifying unnecessary hospitalizations.

Patients with chest pain made up the largest diagnosis grouping, and these patients returned to the ED with the same frequency as the entire cohort. Recent literature has shown that the risk of having a cardiac event after a negative ED evaluation for cardiac chest pain is extremely low. For example, the HEART Pathway, a prospectively validated study that combined the HEART risk stratification score with serial cardiac biomarker testing at 0 and 3 hours, identified a large group of patients presenting to the ED who were at very low risk (~1%) of having a major adverse cardiac event within 30 days.12 In our study, although there was 1 patient who initially presented with chest pain and had a nonfatal STEMI within 30 days, those who presented with chest pain had reduced odds of hospitalization within 30 days of an index consultation compared with the rest of the cohort. Admission for further risk stratification with a stress test for low-risk patients has not been shown to confer greater benefit and does not identify preventable bad outcomes.13,14

We identified several diagnoses with a higher risk of return to the ED: alcohol-related diagnoses, abdominal pain, and sickle cell disease with crisis. Two of these groups, patients with alcohol-related diagnoses and sickle cell disease, are known to have high rates of healthcare utilization, especially those covered by Medicaid.15 Our hospitalist group has published clinical protocols for evaluating and caring for both of these groups of patients.16,17 In this study, patients presenting with alcohol-related diagnoses and abdominal pain had more than 3 times the odds of returning to the ED within 30 days compared with the entire cohort. We suspect that sickle cell disease with crisis also likely conveys a higher risk of return to the ED, although the total number of patient encounters was low and the adjusted OR did not reach statistical significance.

 
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