Boston, MA -- Nearly one in five Americans will visit an emergency department (ED) each year, meaning that physicians make the decision to admit or discharge a patient from the ED hundreds of thousands of times daily, but little is known about how patients fare after they are sent home from the ED. Researchers at Brigham and Women's Hospital measured how often generally healthy Medicare enrollees died in the seven days after being discharged home, by tracking over 16 million visits to U.S. EDs.
The findings are published in the February 1 edition of the British Medical Journal.
"There's a lot of policy interest in reducing unnecessary admissions from the ED," said Ziad Obermeyer, MD, MPhil, a staff physician in the Department of Emergency Medicine at BWH. "We know that hospitals vary a lot in how often they admit patients to the hospital from the ED, but we don't know whether this matters for patient outcomes."
Researchers found that, each year, about 10,000 generally healthy patients die in the seven days after discharge from the ED. Heart disease and COPD were the most common causes of death, but narcotic overdose was also a leading cause, largely after visits for pain and injuries.
These early deaths were concentrated in hospitals that admitted few patients to the hospital from the ED, hospitals that are often viewed as models by policy makers because of their low costs. By contrast, deaths were far less frequent in large, university-affiliated EDs with higher admission rates and higher costs, even though the population served by these EDs was generally less healthy when they walked in the front door of the ED.
Patients discharged with a diagnosis of confusion, shortness of breath, or generalized weakness were more likely to die, while those with chest pain were at significantly lower risk. Researchers analyzed data from Medicare claims that covered ED visits from 2007-2012 to identify patients who died in the week after discharge. Patients with known serious illnesses or diagnoses of life threatening conditions in the ED and those over 90 years old, or receiving palliative care were excluded.
"The variation in outcomes that we observed may be linked to gaps in medical knowledge about which patients need more attention from physicians, as well as the geographic and socioeconomic context of emergency care. Access to resources varies dramatically across hospitals," said Obermeyer, who is also an assistant professor at Harvard Medical School. "Obviously not all patients can or should be admitted to the hospital. But we need to focus on admitting the right patients, rather than admitting more or less. I'm optimistic that advanced analytics and better data will help physicians with these kinds of decisions in the future."
This study was funded by the National Institutes of Health and the Laura and John Arnold Foundation.
Paper cited: Obermeyer Z, MD, MPhil et al. "Early death after discharge from emergency departments: analysis of national US insurance claims data," BMJ-US, DOI: 10.1136/bmj.j239
Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 4.2 million annual patient visits and nearly 46,000 inpatient stays, is the largest birthing center in Massachusetts and employs nearly 16,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Brigham Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 3,000 researchers, including physician-investigators and renowned biomedical scientists and faculty supported by nearly $666 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative as well as the TIMI Study Group, one of the premier cardiovascular clinical trials groups. For more information, resources and to follow us on social media, please visit BWH's online newsroom.