Following a hospitalization, patients face many challenges as they transition home. A new study of this vulnerable period published by Yale School of Medicine researchers in JAMA found that a substantial number of patients return to the emergency department soon after leaving the hospital, and, while such patients are not usually readmitted, the study raises concerns that many more patients require acute medical care after hospital discharge than previously recognized.
A hospital's readmission rate is a marker of hospital quality of care and the success of patient transitions to outpatient care. However, hospital readmission rates may not tell the whole story.
"It's frustrating to see people ending up back in the emergency room so soon after leaving the hospital," said the study's lead author Anita Vashi, M.D., a Robert Wood Johnson clinical scholar at Yale. "It makes me wonder about the cause. Are we not educating them well enough about how to safely transition home? Or do we not have capacity in the system for their care team to coordinate follow-up care if they have a complication? Either way, care that is fragmented in this manner can lead to conflicting recommendations, medication errors, distress, and higher costs."
Vashi and her team studied over five million patients who were discharged from acute care hospitals across three states — California, Florida, and Nebraska — in 2008-2009. Nearly 18% of hospitalized patients returned to either the emergency room or were readmitted within 30 days following discharge. Medicare beneficiaries had even higher rates. Visits to the emergency room, which are not currently measured by hospital readmission rates, accounted for nearly 40% of all visits back to the hospital within 30 days after discharge.
"The big question is how many of these emergency room visits could have been avoided by tightening up our healthcare system, and ensuring close collaboration and communication between patients and their health providers inside and outside the hospital," said senior author Cary Gross, M.D., associate professor of internal medicine at Yale School of Medicine and director of the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) center at Yale. "Future work should focus on identifying how to decrease the need for patients to seek emergency room care right after they leave the hospital."
Conditions with the highest emergency room rates were related to mental health, drug and alcohol abuse, and prostate issues. "High and varying rates of emergency room utilization suggest there is potential to improve care coordination and acute care delivery," said Vashi. "If we don't expand our view of post-acute care from readmissions to include emergency room visits, we will severely underestimate patient needs and system resources required to care tor them."
Other study authors include Justin P. Fox, M.D., Brendan G. Carr M.D., Gail D'Onofrio M.D., Jesse M. Pines M.D., and Joseph S. Ross M.D.
The study was supported by the Robert Wood Johnson Foundation; the National Institute on Aging (Ross); the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program (Ross); and a career development award to Carr K08 AG032886 from the Agency for Healthcare Research and Quality.
Citation: JAMA 2013;309(4):364-371; (Jan. 23/30); Available pre-embargo to the media at http://media.jamanetwork.com
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