Nearly one in five Americans will visit an emergency department (ED) each year, meaning that physicians make the decision to admit or discharge patients from EDs hundreds of thousands of times daily—but little is known about how patients fare after they are sent home. Researchers at Brigham and Women’s Hospital tracked more than 16 million visits to U.S. EDs to determine how often generally healthy Medicare enrollees died during the seven days after being discharged home. Their findings were published in the British Medical Journal.
“There’s a lot of policy interest in reducing unnecessary admissions from the ED,” said Ziad Obermeyer, MD, MPhil, an assistant professor at Harvard Medical School. “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.”
The researchers found that, each year, approximately 10,000 generally healthy patients die within the seven days after discharge from an ED. Heart disease and chronic obstructive pulmonary disease 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. In 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 into 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 to 2012 to identify patients who died within the week after discharge. Patients with known serious illnesses or diagnoses of life-threatening conditions in the ED and those older than 90 years of age 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,” Obermeyer said. “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.”