Revisit rates and associated costs after an emergency department encounter: a multistate analysis

Seventy-two-hour Return Initiative: Improving Emergency Department Discharge to Decrease Returns

Unscheduled return visits within 72 hours of discharge account for 4% of pediatric emergency department (ED) visits each year and are a quality indicator of ED care. This project aimed to reduce the unexpected 72-hour return visit rate for a network of ED and urgent cares (UC) by improving discharge processes.

The safety of home discharge for low-risk emergency department patients presenting with coronavirus-like symptoms during the COVID-19 pandemic: A retrospective cohort study

Objective

There is minimal evidence describing outcomes for emergency department (ED) patients with suspected coronavirus disease 2019 (COVID‐19) infection who are not hospitalized. The study objective was to assess 30‐day outcomes (ED revisit, admission, ICU admission, and death) for low‐risk patients discharged after ED evaluation for COVID‐19.

Methods

This was a retrospective cohort study of patients triaged to a COVID‐19 surge area within an urban ED and discharged between March 12 and April 6. Physicians were encouraged to discharge patients if they were well‐appearing with few comorbidities. Data were collected from review of medical records and phone follow‐up, and the analysis was descriptive.

Results

Of 452 patients, the median age was 38, and 61.7% had no comorbidities. Chest radiographs were performed for 50.4% of patients and showed infiltrates in 14% of those tested. Polymerase chain reaction testing was performed for 28.3% of patients during the index ED visit and was positive in 35.9% of those tested. Follow‐up was achieved for 75.4% of patients. ED revisits occurred for 13.7% of patients. The inpatient admission rate at 30 days was 4.6%, with 0.7% requiring intensive care. Median number of days between index ED evaluation and return for admission was 5 (interquartile range 3–7, range 1–17). There were no known deaths.

Conclusions

A minority of low‐risk patients with suspected COVID‐19 will require hospitalization after being discharged home from the ED. Outpatient management is likely safe for well‐appearing patients with normal vital signs, but patients should be instructed to return for worsening symptoms including labored breathing. Future work is warranted to develop and validate ED disposition guidelines.

Patients over Age 75 Are at Increased Risk of Emergency Department Visit and Hospitalization Following Colonoscopy

BACKGROUND

The age to stop screening or surveillance colonoscopy is not well established, and unplanned hospital use after colonoscopy in the elderly is not well understood.

AIMS

To evaluate unplanned emergency department (ED) visits and hospitalization in patients over 75 within 7 days of outpatient colonoscopy.

METHODS

In this retrospective, single-center, cohort study, we reviewed outpatient screening or surveillance colonoscopies in patients ≥ 50 in a tertiary care academic medical center or affiliated facility between January 2008 and September 2013. Colonoscopies were divided by age based on USPSTF recommendations. The rate of ED visits and hospitalizations per colonoscopy for each age-group was determined. Predictors of ED visit and hospitalization were assessed through univariate and multivariate logistic regressions, and mortality following colonoscopy was evaluated using Kaplan-Meier analysis.

RESULTS

A total of 30,409 colonoscopies were performed in 27,173 patients (51% male) by 40 endoscopists. ED visits occurred after 188 colonoscopies (0.62%). Age over 75 years was independently associated with ED visit (OR 1.58, 95% CI 1.05-2.37, p = 0.027) and hospitalization (OR 3.7, 95% CI 2.03-6.73, p < 0.001) within 7 days of colonoscopy. Higher number of medication classes, recent ED visit, polypectomy, and endoscopic mucosal resection were also independent variables associated with ED utilization after procedure. The mortality rate at the end of the follow-up (median 4.4; IQR 2.7-6 years) was 1.9, 8.6, and 15.8% for the age-groups 50-75, 76-85, and > 85 years, respectively.

CONCLUSION

Patients over age 75 are 1.6 times as likely to use the ED and 3.7 times as likely to be hospitalized after colonoscopy. Further prospective studies are needed to assess the risk/benefit of nondiagnostic colonoscopy in geriatric patients.

Identifying return visits to the Emergency Department: A multi-centre study

BACKGROUND

Patients who return to the Emergency Department (ED) for the same complaint are known to be at risk of adverse events. Monitoring of return visits is considered a way to measure the quality of care provided in the ED, although the most commonly used benchmark of 48h lacks evidence. This study aimed to describe the incidence, characteristics and outcomes of patients with unplanned return visits. The study also aimed to determine the capture rate of the 48-h benchmark using an all-inclusive method of return visit identification.

METHODS

A retrospective cross-sectional study was conducted across three EDs in Sydney, New South Wales from July 1st, 2017 to June 30th, 2018. Visits that occurred within 28 days with the same or similar presenting complaint following discharge from the ED were classified as a return visit. Data were grouped by index and return visit. Descriptive statistics were used to summarise incidence, patient characteristics and outcomes for all presentations. Categorical data were analysed using Chi square tests. Continuous data were analysed using Mann-Whitney when data were not normally distributed and t-tests when normally distributed.

RESULTS

Of all ED presentations (n=164,598), 5860 (3.6%) were identified as a return visit. Return patients were younger than non-return patients, but those that required admission were older (43 vs 33 years, p=<0.01). Abdominal problems were the most common reason for return followed by urological and mental health. The median time to return was 64:51h (IQR 20:35-226:37). Only 43% of return visits occurred within 48h. Return visits to a different ED accounted for 13.2% of return visits.

CONCLUSION

More than half of ED return visits are missed when the existing benchmark of 48h is used. Current policy makers should consider increasing the 48-h benchmark to more accurately reflect the incidence of return visits. Further investigation into the causal factors for return visits is warranted, particularly in patients with abdominal, urological or mental health complaints.

[Epidemiology, initial diagnosis, and therapy of unexplained abdominal pain in the emergency department]

BACKGROUND

Abdominal pain is one of the most common symptoms of patients who present to the emergency department (ED). The aim of this study was to collect current epidemiological data, the frequency of these findings, and the measures that derived from them.

METHODS

We performed a retrospective analysis in the period between January 1 and June 30, 2016, including all patients who presented to the ED of the Caritas Hospital St. Josef in Regensburg (teaching hospital with an academic urology and gynecology department, about 32,000 patients in the ED per year) and were categorized as "abdominal pain in adults" using the Manchester Triage System (MTS).

RESULTS

The study population consisted of 1417 patients (9.8% of all ED patients). The admission rate was 48.2%. Vomiting and fever as concomitant symptoms made hospitalization more likely (p = 0.00). Almost half of the patients had nonspecific abdominal pain (28.2%), gynecological causes (13.2%), or suspected acute appendicitis (6.7%). In all, 10% of patients received an abdominal CT investigation; 73% of the patients presented in the time from 08:00-20:00 h, and more frequently on weekdays (74.2%). Of these patients, 6.4% returned after discharge because of persisting or worsening symptoms. Finally, 58.6% of outpatients and 77.5% of inpatients received further treatment recommendations for new pharmacologic therapy (e.g., analgesics, proton pump inhibitors, antibiotics).

CONCLUSION

A variety of epidemiological data of our collective could be analyzed, which should be transferable to many other German EDs. The MTS shows a high reliability in terms of conversion rate in abdominal pain; despite comprehensive emergency diagnostics, a relevant proportion of complaints remain unclear.

Influence of Overcrowding in the Emergency Department on Return Visit within 72 Hours

This study was conducted to determine whether overcrowding in the emergency department (ED) affects the occurrence of a return visit (RV) within 72 h. The crowding indicator of index visit was the average number of total patients, patients under observation, and boarding patients during the first 1 and 4 h from ED arrival time and the last 1 h before ED departure. Logistic regression analysis was conducted to determine whether each indicator affects the occurrence of RV and post-RV admission. Of the 87,360 discharged patients, 3743 (4.3%) returned to the ED within 72 h. Of the crowding indicators pertaining to total patients, the last 1 h significantly affected decrease in RV (p = 0.0046). Boarding patients were found to increase RV occurrence during the first 1 h (p = 0.0146) and 4 h (p = 0.0326). Crowding indicators that increased the likelihood of admission post-RV were total number of patients during the first 1 h (p = 0.0166) and 4 h (p = 0.0335) and evaluating patients during the first 1 h (p = 0.0059). Overcrowding in the ED increased the incidence of RV and likelihood of post-RV admission. However, overcrowding at the time of ED departure was related to reduced RV.

To Admit or Not to Admit: Emergency Department Discharges After Request for Medicine Admission

BACKGROUND

The decision to discharge versus admit a patient from the emergency department (ED) carries significant consequences to the patient and healthcare system.

METHODS

We evaluated all ED visits at a single facility from January 1-December 31, 2015, where the ED provider initially requested admission to medicine; however, following medicine evaluation, the patient was discharged from the ED.

RESULTS

8.1% of medicine referrals resulted in discharge from the ED after referral for admission. 62.6% lacked documentation by medicine or another consulting service. Patients completed clinic follow-up within 7 or 30 days, 52.8% and 76.0% respectively. Emergency department revisit rates were similar for patients not referred versus referred for admission (8.0% vs. 8.1%, 13.3% vs. 14.6%, and 29.9% vs. 28.9% at 3, 7, and 30 days, respectively p-value > .05). Hospital admission during the follow-up period was also similar for these two groups (1.8% vs. 2.8%, 3.9% vs. 5.7%, and 11.3% vs. 15.0% at 3, 7, and 30 days, respectively p-value > .05).

CONCLUSIONS

Patients discharged from the ED after referral for medicine admission were not at significantly increased risk of subsequent ED revisit or hospital admission compared with nonreferred patients. This study illustrates the opportunity for collaboration between ED and medicine providers to refine disposition plans for patients who may fall into the "gray zone."

The Association Between Emergency Department Revisit and Elderly Patients

BACKGROUND

Emergency department (ED) revisits may be associated with a higher percentage of adverse events and increased costs. Our hospital is a university affiliation hospital accepted regional referral patients, and located in the region in Taiwan with the highest percentage of elderly people. In this study, we attempted to identify whether old age was a risk factor of ED revisit.

METHODS

Patients who visited the ED from July 2011 to June 2016 were included. Factors associated with revisit were collected from medical information database. A total of 239,405 patients were included in our study, with 13,272 having ED revisits within 72 hours. Chi square and independent t test were applied for univariable factors, and a logistic regression model was used for multivariable analysis.

RESULTS

Old age (age ≥ 65 years) was found to be a risk factor for ED revisit (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.09-1.19). Diagnosis, pulse rate, diastolic blood pressure, fever, pain management, paracentesis, triage level, registration category, male gender, discharge status, and major illness may have some effect on ED revisit.

CONCLUSIONS

In our patients, old age is a risk factor for ED revisit; however, only a weak association was found.

Revisits, readmissions, and outcomes for pediatric traumatic brain injury in California, 2005-2014

Long-term outcomes related to emergency department revisit, hospital readmission, and all-cause mortality, have not been well characterized across the spectrum of pediatric traumatic brain injury (TBI). We evaluated emergency department visit outcomes up to 1 year after pediatric TBI, in comparison to a referent group of trauma patients without TBI. We performed a longitudinal, retrospective study of all pediatric trauma patients who presented to emergency departments and hospitals in California from 2005 to 2014. We compared emergency department visits, dispositions, revisits, readmissions, and mortality in pediatric trauma patients with a TBI diagnosis to those without TBI (Other Trauma patients). We identified 208,222 pediatric patients with an index diagnosis of TBI and 1,314,064 patients with an index diagnosis of Other Trauma. Population growth adjusted TBI visits increased by 5.6% while those for Other Trauma decreased by 40.7%. The majority of patients were discharged from the emergency department on their first visit (93.2% for traumatic brain injury vs. 96.5% for Other Trauma). A greater proportion of TBI patients revisited the emergency department (33.4% vs. 3.0%) or were readmitted to the hospital (0.9% vs. 0.04%) at least once within a year of discharge. The health burden within a year after a pediatric TBI visit is considerable and is greater than that of non-TBI trauma. These data suggest that outpatient strategies to monitor for short-term and longer-term sequelae after pediatric TBI are needed to improve patient outcomes, lessen the burden on families, and more appropriately allocate resources in the healthcare system.

Application of the Informatics Stack framework to describe a population-level emergency department return visit continuous quality improvement program

INTRODUCTION

Population health programs are increasingly reliant on Health Information Technology (HIT). Program HIT architecture description is a necessary step prior to evaluation. Several sociotechnical frameworks have been used previously with HIT programs. The Informatics Stack is a novel framework that provides a thorough description of HIT program architecture. The Emergency Department Return Visit Quality Program (EDRVQP) is a population-level continuous quality improvement (QI) program connecting EDs across Ontario. The objectives of the study were to utilize the Informatics Stack to provide a description of the EDRVQP HIT architecture and to delineate population health program factors that are enablers or barriers.

MATERIALS AND METHODS

The Informatics Stack was used to describe the HIT architecture. A qualitative study was completed with semi-structured interviews of key informants across stakeholder organizations. Emergency departments were selected randomly. Purposive sampling identified key informants. Interviews were conducted until saturation. An inductive qualitative analysis using grounded theory was completed. A literature review of peer-reviewed background literature, and stakeholder organization reports was also conducted.

RESULTS

23 business actors from 15 organizations were interviewed. The EDRVQP architecture description is presented across the Informatics Stack levels. The levels from most comprehensive to most basic are world, organization, perspectives/roles, goals/functions, workflow/behaviour/adoption, information systems, modules, data/information/knowledge/wisdom/algorithms, and technology. Enabling factors were the high rate of electronic health record adoption, legislative mandate for data collection, use of functional data standards, implementation flexibility, leveraging validated algorithms, and leveraging existing local health networks. Barriers were privacy legislation and a high turn-around time.

DISCUSSION

The Informatics Stack provides a robust approach to thoroughly describe the HIT architecture of population health programs prior to program replication. The EDRVQP is a population health program that illustrates the pragmatic use of continuous QI methodology across a population (provincial) level.

Large observational study on risks predicting emergency department return visits and associated disposition deviations

Objective

A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD.

Methods

We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders.

Results

A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits.

Conclusion

Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.

The Uropathogenic Escherichia coli Subclone Sequence Type 131-H30 Is Responsible for Most Antibiotic Prescription Errors at an Urgent Care Clinic

BACKGROUND

The pandemic spread of antibiotic resistance increases the likelihood of ineffective empirical therapy. The recently emerged fluoroquinolone-resistant Escherichia coli sequence type (ST) 131-H30R subclone (H30) is a leading cause of multidrug-resistant urinary tract infection (UTI) and bloodstream infection worldwide.

METHODS

We studied the relative impact of H30 on the likelihood that bacteria isolated from urine of urgent care patients would be resistant to the empirically prescribed antibiotic regimen for UTI.

RESULTS

Of 750 urinalysis-positive urine samples from urgent care patients with suspected UTI, 306 (41%) yielded E. coli, from 35 different clonal groups (clonotypes). H30 predominated (14% prevalence overall), especially among older patients (age ≥70 years: 26%) and those with diabetes (43%) or urinary catheterization (60%). Resistance to the empirically selected antibiotic regimen occurred in 16% (40/246) of patients overall, 28% (20/71) of older patients, 30% (8/27) of patients with diabetes, 60% (3/5) of catheterized patients, and 71% (22/30) of those with H30. H30's contribution to such mismatched antibiotic selection was 55% overall, 70% among older patients, and 100% among patients with diabetes or a urinary catheter. Among patients with ≥2 of these factors (older age, diabetes, or urinary catheter), 24% of all urinalysis-positive urine samples yielded H30, with a 92% likelihood of resistance to the selected empirical therapy.

CONCLUSIONS

The multidrug-resistant H30 subclone of E. coli ST131 is responsible for the great majority of mismatched empirical antibiotic prescriptions for suspected UTI at an urgent care clinic among patients ≥70 years old or with diabetes or urinary catheterization.

Incidence, characteristics and outcomes of patients that return to Emergency Departments. An integrative review

BACKGROUND

Unplanned return visits account for up to 5% of Emergency Department presentations in Australia and have been associated with adverse events and increased costs. A large number of studies examine the incidence, characteristics and outcomes of unplanned return visits but few studies examine the reasons for return from a patient perspective. The objective of this integrative review was to determine the incidence, characteristics, outcomes and reasons for unplanned return visits to Emergency Departments.

METHOD

An integrative literature review design was employed to conduct a structured search of the literature using the databases CINAHL, MEDLINE, PubMed, ProQuest and EMBASE (inception to June 2018). Results were screened using predefined criteria and final studies collated and appraised using a quality assessment tool.

RESULTS

Fifty-two primary research articles were included in the review. The timeframe used to capture unplanned return visits varied and the incidence ranged between 0.07% and 33%. The majority of patients who return unplanned to the Emergency Department are subsequently discharged (51% and 90%) without an adverse event.

CONCLUSION

There is no consensus on the timeframe employed to classify unplanned return visits to the Emergency Department and the commonly used 72h lacks evidence. Routine statewide data linkage to capture return visits to other facilities is needed to ensure accurate data about this vulnerable patient group. Further research that focuses on patient and clinician perspectives is required to facilitate the development of local strategies to reduce the incidence of avoidable unplanned return visits.

Unscheduled early revisit to emergency department

Background:

Unscheduled revisits to the emergency department may present a considerable additional workload.

Objectives:

This study investigated the risk factors contributing to adverse event during unscheduled early revisit to Emergency Department Hospital Universiti Sains Malaysia.

Methods:

A retrospective cohort study was conducted from January 2014 to January 2015 to character the nature of unscheduled early revisits to Emergency Department Hospital Universiti Sains Malaysia. It included all patients 18 years old and above, revisited emergency department within 9 days post discharge from emergency department.

Results:

Data were collected from 492 case records. The rate of emergency department unplanned revisits within 9 days of previous emergency department discharge was 0.66% for the study period. Risk factors for revisit included advance age, pre-existing co-morbidities, duration spent during first emergency department visit and health care system–related error. The independent predictors of morbidity were diabetes mellitus (odds ratio, 2.07; 95% confidential interval, 1.08–3.96), respiratory disease (odds ratio, 2.42; 95% confidential interval, 1.18–4.98), gastrointestinal disease (odds ratio, 5.93; 95% confidential interval: 1.29, 27.35), nervous system disease (odds ratio, 4.65; 95% confidential interval: 1.27, 17.02), duration spent more than 6 h during first emergency department visit (odds ratio, 3.05; 95% confidential interval: 1.53, 6.07), and medical error leading to admission (odds ratio, 8.85; 95% confidential interval: 4.43, 17.67). The overall mortality rate was 0.2% (1/492).

Conclusion:

Emergency department physicians need to be extra vigilant when managing patients with risk factors, particularly the modifiable risk factors, to curb emergency department revisit.

Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study

BACKGROUND

Studying diagnostic error at the population level requires an understanding of how diagnoses change over time.

OBJECTIVE

To use inter-hospital transfers to examine the frequency and impact of changes in diagnosis on patient risk, and whether health information exchange can improve patient safety by enhancing diagnostic accuracy.

DESIGN

Diagnosis coding before and after hospital transfer was merged with responses from the American Hospital Association Annual Survey for a cohort of patients transferred between hospitals to identify predictors of mortality.

PARTICIPANTS

Patients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013.

MAIN MEASURES

We identified discordant Elixhauser comorbidities before and after transfer to determine the frequency and developed a weighted score of diagnostic discordance to predict mortality. This was included in a multivariate model with inpatient mortality as the dependent variable. We investigated whether health information exchange (HIE) functionality adoption as reported by hospitals improved diagnostic discordance and inpatient mortality.

KEY RESULTS

Discordance in diagnoses occurred in 85.5% of all patients. Seventy-three percent of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11 95% CI 1.10-1.11, p < 0.001) and allowed for improved mortality prediction. Bilateral hospital HIE participation was associated with reduced diagnostic discordance index (3.69 vs. 1.87%, p < 0.001) and decreased inpatient mortality (OR 0.88, 95% CI 0.89-0.99, p < 0.001).

CONCLUSIONS

Diagnostic discordance commonly occurred during inter-hospital transfers and was associated with increased inpatient mortality. Health information exchange adoption was associated with decreased discordance and improved patient outcomes.

Implementation and impact analysis of a transitional care pathway for patients presenting to the emergency department with cardiac-related complaints

Background

Cardiac-related complaints are leading drivers of Emergency Department (ED) utilization. Although a large proportion of cardiac patients can be discharged with appropriate outpatient follow-up, inadequate care coordination often leads to high revisit rates or unnecessary admissions. We evaluate the impact of implementing a structured transitional care pathway enrolling low-risk cardiac patients on ED discharges, 30-day revisits and admissions, and institutional revenues.

Methods

We prospectively enrolled eligible patients presenting to a single-center Emergency Department over a 12-month period. Standardized risk measures were used to identify patients suitable for early discharge with cardiology follow-up within 5 days. The primary endpoints were rates of discharge from the ED and 30-day ED revisit and admission rates, with a secondary endpoint including 30-day returns for myocardial infarction. A cost analysis of the program’s impact on institutional revenues was performed.

Results

Among patients presenting with cardiac-related complaints, rates of discharge from the ED increased from 44.4 to 56.6% (p < 0.0001). Enrollment in the transitional care pathway was associated with a reduced risk of cardiac-related ED revisits (RR 0.22, p < 0.0001), all-cause ED revisits (RR 0.30, p < 0.0001), and admission at second ED visit (RR 0.56, p = 0.0047); among enrolled patients, the 30-day rate of return with a myocardial infarction was 0.35%. No significant reductions were seen in 30-day cardiac-related and all-cause revisits in the 12-months following transitional care pathway implementation; however, there was a significant reduction in admissions at second ED visit from 45.6 to 37.7% (p = 0.0338). An early gender disparity in care delivery was identified in the first 120 days following program implementation that was subsequently eliminated through targeted intervention. There was an estimated decline in institutional revenue of $300 per enrolled patient, driven predominantly by a reduction in admissions.

Conclusions

A structured transitional care pathway identifying low-risk cardiac patients who may be safely discharged from the ED can be effective in shifting care delivery from hospital-based to lower cost ambulatory settings without adversely impacting 30-day ED revisit rates or patient outcomes.

The feasibility of an inter-professional transitions of care service in an older adult population

BACKGROUND

Older adults discharged from the Emergency Department (ED) are at high risk for medication interactions and side effects; examples of practice models addressing this transition of care are lacking.

METHODS

This was a prospective cohort study for adults in one of two urban community EDs. Patients ≥50 years of age discharged with at least one new, non-schedule II prescription medication were included. Patients had the option of three transitions of care services: 1) pharmacist-only with home delivery of discharge medications and full medication reconciliation, 2) pharmacist and home health care, including home delivery, medication reconciliation, and a visit from a home health nurse, or 3) either of the above without home delivery.

RESULTS

Over seven months, 440 ED patients were screened. Of those, 43 patients were eligible, and three patients elected to join the study. All three patients selected pharmacy-only. Identified barriers to enrollment include the rate of schedule II prescriptions from the ED (53% of potential patients) and high patient loyalty to their community pharmacist.

CONCLUSIONS

A pharmacy and home health care transitions of care program was not feasible at an urban community ED. While the pharmacist team identified and managed multiple medication issues, most patients did not qualify due to prescriptions ineligible for delivery. Patients did not want pharmacist or home health nurse involvement in their post ED visit care, many due to loyalty to their community pharmacy. Multiple barriers must be addressed to create a successful inter-professional transition of care model.

Accuracy of Internet-Based Patient Self-Report of Postdischarge Health Care Utilization and Complications Following Orthopedic Procedures: Observational Cohort Study

Background

The accuracy of patient self-report of health care utilization and complications has yet to be determined. If patients are accurate and engaged self-reporters, collecting this information in a manner that is temporally proximate to the health care utilization events themselves may prove valuable to health care organizations undertaking quality improvement initiatives for which such data are often unavailable.

Objective

The objective of this study was to measure the accuracy of patient self-report of health care utilization and complications in the 90 days following orthopedic procedures using an automated digital patient engagement platform.

Methods

We conducted a multicenter real-world observational cohort study across 10 orthopedic practices in California and Nevada. A total of 371 Anthem members with claims data meeting inclusion criteria who had undergone orthopedic procedures between March 1, 2015, and July 1, 2016, at participating practices already routinely using an automated digital patient engagement platform for asynchronous remote guidance and telemonitoring were sent surveys through the platform (in addition to the other materials being provided to them through the platform) regarding 90-day postencounter health care utilization and complications. Their self-reports to structured survey questions of health care utilization and complications were compared to claims data as a reference.

Results

The mean age of the 371 survey recipients was 56.5 (SD 15.7) years, 48.8% (181/371) of whom were female; 285 individuals who responded to 1 or more survey questions had a mean age of 56.9 (SD 15.4) years and a 49.5% (141/285) female distribution. There were no significant differences in demographics or event prevalence rates between responders and nonresponders. With an overall survey completion rate of 76.8% (285/371), patients were found to have accuracy of self-report characterized by a kappa of 0.80 and agreement of 0.99 and a kappa of 1.00 and agreement of 1.00 for 90-day hospital admissions and pulmonary embolism, respectively. Accuracy of self-report of 90-day emergency room/urgent care visits and of surgical site infection were characterized by a kappa of 0.45 and agreement of 0.96 and a kappa of 0.53 and agreement of 0.97, respectively. Accuracy for other complications such as deep vein thrombosis, hemorrhage, severe constipation, and fracture/dislocation was lower, influenced by low event prevalence rates within our sample.

Conclusions

In this multicenter observational cohort study using an automated internet-based digital patient engagement platform, we found that patients were most accurate self-reporters of 90-day hospital admissions and pulmonary embolism, followed by 90-day surgical site infection and emergency room/urgent care visits. They were less accurate for deep vein thrombosis and least accurate for hemorrhage, severe constipation, and fracture/dislocation. A total of 76.8% (285/371) of patients completed surveys without the need for clinical staff to collect responses, suggesting the acceptability to patients of internet-based survey dissemination from and collection by clinical teams. While our methods enabled detection of events outside of index institutions, assessment of accuracy of self-report for presence and absence of events and nonresponse bias analysis, low event prevalence rates, particularly for several of the complications, limit the conclusions that may be drawn for some of the findings. Nevertheless, this investigation suggests the potential that engaging patients in self-report through such survey modalities may offer for the timely and accurate measurement of matters germane to health care organizations engaged in quality improvement efforts post discharge.

Urology Consultation and Emergency Department Revisits for Children with Urinary Stone Disease

PURPOSE

We determined the association between urology consultation and emergency department revisits for children with urinary stones.

MATERIALS AND METHODS

This retrospective cohort study included patients 18 years old or younger who presented to an emergency department in South Carolina with a urinary stone from 1997 to 2015. The primary exposure was urology consultation during the index emergency department visit. The primary outcome was a stone related emergency department revisit occurring within 180 days of discharge from an index emergency department visit. Secondary outcomes included computerized tomography use, inpatient admission and emergent surgery.

RESULTS

Of 5,642 index emergency department visits for acute urinary stones 11% resulted in at least 1 stone related emergency department revisit within 180 days. Of revisits 59% occurred within 30 days of discharge and 39% were due to pain. The odds of emergency department revisit were highest within the first 48 hours of discharge home (OR 22.6, 95% CI 18.0 to 28.5) and rapidly decreased thereafter. Urology consultation was associated with a 37% lower adjusted odds of emergency department revisit (OR 0.63, 95% CI 0.44 to 0.90) and 68% lower odds of computerized tomography use across all emergency department visits (OR 0.32, 95% CI 0.15 to 0.69). Among patients who revisited the emergency department the frequency of pain complaints was 27% in those with a urological consultation at the index visit and 39% in those without.

CONCLUSIONS

Urology consultation was associated with decreased emergency department revisits and computerized tomography use in pediatric patients with urinary stones. Future studies should identify patients who benefit most from urology consultation and ascertain processes of care that decrease emergency department revisits among high risk patients.

Comparing Statewide and Single-center Data to Predict High-frequency Emergency Department Utilization Among Patients With Asthma Exacerbation

BACKGROUND

Previous studies examining high-frequency emergency department (ED) utilization have primarily used single-center data, potentially leading to ascertainment bias if patients visit multiple centers. The goals of this study were 1) to create a predictive model to prospectively identify patients at risk of high-frequency ED utilization for asthma and 2) to examine how that model differed using statewide versus single-center data.

METHODS

To track ED visits within a state, we analyzed 2011 to 2013 data from the New York State Healthcare Cost and Utilization Project State Emergency Department Databases. The first year of data (2011) was used to determine prior utilization, 2012 was used to identify index ED visits for asthma and for demographics, and 2013 was used for outcome ascertainment. High-frequency utilization was defined as 4+ ED visits for asthma within 1 year after the index visit. We performed analyses separately for children (age < 21 years) and adults and constructed two models: one included all statewide (multicenter) visits and the other was restricted to index hospital (single-center) visits. Multivariable logistic regression models were developed from potential predictors selected a priori. The final model was chosen by evaluating model performance using Akaike's Information Criterion scores, 10-fold cross-validation, and receiver operating characteristic curves.

RESULTS

Among children, high-frequency ED utilization for asthma was observed in 2,417 of 94,258 (2.56%) using all statewide visits, compared to 1,853 of 94,258 (1.97%) for index hospital visits only. Among adults, the corresponding results were 7,779 of 159,874 (4.87%) and 5,053 of 159,874 (3.16%), respectively. In the multicenter visit model, the area under the curve (AUC) from 10-fold cross-validation for children was 0.70 (95% confidence interval [CI] = 0.69-0.72), compared to 0.71 (95% CI = 0.69-0.72) in the single-center visit model. The corresponding AUC results for adults were 0.76 (95% CI = 0.76-0.77) and 0.76 (95% CI = 0.75-0.77), respectively.

CONCLUSION

Data available at the index ED visit can predict subsequent high-frequency utilization for asthma with AUC ranging from 0.70 to 0.76. Model accuracy was similar regardless of whether outcome ascertainment included all statewide visits (multicenter) or was limited to the index hospital (single-center).

Timing and Location of Emergency Department Revisits

BACKGROUND

Emergency department (ED) revisits are used as a measure of care quality. Many EDs measure only revisits to the same facility, underestimating true rates. We sought to determine the frequency, location, and predictors of ED revisits to the same or a different ED.

METHODS

We studied ED discharges for children <18 years old in Maryland and New York in the statewide ED and inpatient databases. Revisits were defined as ED visits within 7 days of an index visit. Our primary outcome was the proportion of revisits that were different-hospital revisits (DHRs). We measured the underestimation of total revisits when only same-hospital revisits were measured. We determined the risk of DHR by quartile of annual ED pediatric volume, adjusting for case mix, insurance, state, and urban location.

RESULTS

Revisits across 261 EDs occurred after 5.9% of 4.3 million discharges. A per-ED median 21.9% of revisits were DHRs (interquartile range 14.2%-34.6%). Measuring only same-hospital revisits underestimated total revisits by 17.4%. The proportions of revisits that were DHRs by increasing volume quartile were 28.1%, 25.5%, 22.6%, and 14.5%. The adjusted risk of DHR was lower for increasing quartiles of pediatric volume (adjusted odds ratio for highest versus lowest quartile 0.27; 95% confidence interval, 0.19-0.36).

CONCLUSIONS

Measuring ED revisits only at the index ED significantly underestimates total revisits. Lower pediatric volume is associated with higher DHRs as a proportion of revisits. When using revisits as a measure of emergency care quality, effort should be made to assess revisits to different EDs.

Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children

OBJECTIVE

The objective was to test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit.

METHODS

This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as "ED return admissions" (discharged at ED index visit and admitted at return visit) or "readmissions" (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to "index admissions without return admission" (admitted at ED index visit without 7-day return visit admission).

RESULTS

Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = -$193; 95% CI = -$479 to $93) compared to index admissions without return admission.

CONCLUSIONS

Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.

Acute Crisis Care for Patients with Mental Health Crises: Initial Assessment of an Innovative Prehospital Alternative Destination Program in North Carolina

OBJECTIVE

Emergency Departments (ED) are overburdened with patients experiencing acute mental health crises. Pre-hospital transport by Emergency Medical Services (EMS) to community mental health and substance abuse treatment facilities could reduce ED utilization and costs. Our objective was to describe characteristics, treatment, and outcomes of acute mental health crises patients who were transported by EMS to an acute crisis unit at WakeBrook, a North Carolina community mental health center.

METHODS

We performed a retrospective cohort study of patients diverted to WakeBrook by EMS from August 2013-July 2014. We abstracted data from WakeBrook medical records and used descriptive statistics to quantify patient characteristics, diagnoses, length of stay (LOS), and 30-day recidivism.

RESULTS

A total of 226 EMS patients were triaged at WakeBrook. The median age was 38 years, 55% were male, 58% were white, and 38% were uninsured. The most common chief complaints were suicidal ideation or self-harm (46%) and substance abuse (19%). The most common diagnoses were substance-related and addictive disorders (42%), depressive disorders (32%), and schizophrenia spectrum and other psychotic disorders (22%). Following initial evaluation, 28% of patients were admitted to facilities within WakeBrook, 40% were admitted to external psychiatric facilities, 18% were stabilized and discharged home, 5% were transferred to an ED within 4 hours for further medical evaluation, and 5% refused services. The median LOS at WakeBrook prior to disposition was 12.0 hours (IQR 5.4-21.6). Over a 30-day follow-up period, 60 patients (27%) had a return visit to the ED or WakeBrook for a mental health issue.

CONCLUSIONS

A dedicated community mental health center is able to treat patients experiencing acute mental health crises. LOS times were significantly shorter compared to regional EDs. Successful broader programmatic implementation could improve care quality and significantly reduce the volume of patients treated in the ED for acute mental health disorders.

Predictors of post-colonoscopy emergency department use

BACKGROUND AND AIMS

Unplanned hospital visits within 7 days of colonoscopy were recently proposed as a quality measure. It is unknown whether patient, procedure, or endoscopist characteristics predict post-colonoscopy emergency department (ED) visits. Our aim was to determine the incidence and relatedness of ED visits within 7 days of colonoscopy and to identify predictors of post-colonoscopy ED use.

METHODS

In this retrospective, single-center, cohort study, we evaluated outpatient colonoscopies performed at a tertiary academic medical center or affiliated facility between January 2008 and September 2013. We determined the incidence of ED visits within 7 days of colonoscopy and the relatedness of the ED visit to the procedure. We assessed for independent factors associated with ED use within 7 days using logistic regression analysis.

RESULTS

We reviewed 50,319 colonoscopies performed on 44,082 individuals (47% male, median age 59 years) by 40 endoscopists. There were 382 (0.76%) ED visits after colonoscopy, of which 68% were related to the procedure. On multivariate analysis, recent ED visit (odds ratio [OR], 16.60; 95% confidence interval [CI], 12.83-21.48; P < .001), EMR (OR, 4.69; 95% CI, 2.82-7.79; P < .001), number of medication classes (OR, 1.18; 95% CI, 1.11-1.26; P < .001), endoscopist adenoma detection rate (ADR) (OR, 1.14; 95% CI, 1.01-1.29; P = .029), and white race (OR, 0.77; 95% CI, 0.62-0.97; P = .028) were identified as independent variables associated with ED visits after colonoscopy.

CONCLUSIONS

Increased patient complexity, higher endoscopist ADR, and EMR were associated with increased ED use after colonoscopy. Patients at high risk for an unplanned hospital visit within 7 days should be targeted for quality improvement efforts to reduce adverse events and cost.

Factors Affecting Unscheduled Return Visits to the Emergency Department among Minor Head Injury Patients

Study Objectives

Differences between returning and non-returning minor head injury (MHI) emergency department (ED) patients, between the characteristics of the first visit and revisit, and between admitted and nonadmitted returning patients were investigated.

Methods

This was a retrospective study. All discharged ED patients with ICD-9 codes 850.0 to 850.9, 920, and 959.01 in 2013 were enrolled. Patients' demographic data, vital signs, Glasgow Coma Scale, ED diagnosis, length of stay, triage levels, ED examinations performed, and comorbidities were recorded for analysis.

Results

A total of 2,815 patients were enrolled. Of 57 (2%) patients who revisited the ED, 47 (82%) were discharged from the ED and ten (18%) were admitted to the hospital. Patients who returned to the ED were older, and they exhibited more comorbidities. Those who presented with vomiting, triage level of 1 or 2, and GCS score of <15 and who received more blood tests during their first visit were more likely to be admitted when they returned to the ED.

Conclusions

Discharging MHI patients who are older or exhibit comorbidities only when symptoms and concerns are relieved completely, providing clear discharge instructions, and arranging timely clinical follow-ups may help reduce such patients' return rate.

Risk factors for early return visits to the emergency department in patients with urinary tract infection

BACKGROUND

Optimal management of urinary tract infections (UTIs) in the emergency department (ED) is challenging due to high patient turnover, decreased continuity of care, and treatment decisions made in the absence of microbiologic data. We sought to identify risk factors for return visits in ED patients treated for UTI.

METHODS

A random sample of 350 adult ED patients with UTI by ICD 9/10 codes was selected for review. Relevant data was extracted from medical charts and compared between patients with and without ED return visits within 30days (ERVs).

RESULTS

We identified 51 patients (15%) with 59 ERVs, of whom 6% returned within 72h. Nearly half of ERVs (47%) were UTI-related and 33% of ERV patients required hospitalization. ERVs were significantly more likely (P<0.05) in patients with the following: age≥65years; pregnancy; skilled nursing facility residence; dementia; psychiatric disorder; obstructive uropathy; healthcare exposure; temperature≥38 °C heart rate>100; and bacteremia. Escherichia coli was the most common uropathogen (70%) and susceptibility rates to most oral antibiotics were below 80% in both groups except nitrofurantoin (99% susceptible). Cephalexin was the most frequently prescribed antibiotic (51% vs. 44%; P=0.32). Cephalexin bug-drug mismatches were more common in ERV patients (41% vs. 15%; P=0.02). Culture follow-up occurred less frequently in ERV patients (75% vs. 100%; P<0.05).

CONCLUSIONS

ERV in UTI patients may be minimized by using ED-source specific antibiogram data to guide empiric treatment decisions and by targeting at-risk patients for post-discharge follow-up.

Outcomes after observation stays among older adult Medicare beneficiaries in the USA: retrospective cohort study

Objective To characterize rates and trends over time of emergency department treatment-and-discharge stays, repeat observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from observation stays.Design Retrospective cohort study.Setting 4750 hospitals in the USA.Participants Nationally representative sample of Medicare fee for service beneficiaries aged 65 or over discharged after 363 037 index observation stays, 2 540 000 index emergency department treatment-and-discharge stays, and 2 667 525 index inpatient stays from 2006-11.Main outcome measures Rates of emergency department treatment-and-discharge stays, observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from index observation stays. Rates were compared with corresponding outcomes within 30 days of discharge from both index emergency department treatment-and-discharge stays and index inpatient stays.Results Among 363 037 index observation stays resulting in discharge from 2006-11, 30 day rates of emergency department treatment-and-discharge stays were 8.4%, repeat observation stays were 2.9%, inpatient stays were 11.2%, any hospital revisit was 20.1%, and death was 1.8%. Of all revisits, 49.7% were for inpatient stays. Revisit rates for emergency department treatment-and-discharge stays, repeat observation stays, and any hospital revisit increased from 2006-11 (P<0.001 for trend), while 30 day rates of inpatient stays (P=0.054 for trend) and 30 day mortality (P=0.091 for trend) were both unchanged. Averaged over the study period, 30 day rates of any hospital revisit were similar after discharge from index emergency department treatment-and-discharge stays (19.9%) and index observation stays (20.1%), as was 30 day mortality (1.8% for both). Rates of any hospital revisit (21.8%) and death (5.2%) were highest after discharge from index inpatient stays.Conclusions Hospital revisits are common after discharge from observation stays, frequently result in inpatient hospitalizations, and have increased over time among Medicare beneficiaries. As revisit rates are similar after emergency department and observation stays, strategies shown to enhance emergency department transitional care may be reasonable starting points to improve post-observation outcomes.

Short Term Unscheduled Revisits to Paediatric Emergency Department - A Six Year Data

INTRODUCTION

Reviewing the reasons for return visits within 24 hours is a very important method of determining possible problems of emergency health care. Several causes stay behind unscheduled emergency return visits. Therefore, identifying these factors is crucial to set strategies in order to decrease the number of unnecessary visits.

AIM

To define the characteristics of the patients returning to the Paediatric Emergency Department (PED) within 24 hours via determining rate, number and demographic data of patients.

MATERIALS AND METHODS

The present study design involves retrospective data collection of patients who returned to PED within 24 hours after being discharged. Data was included over six year period and was collected from July 1, 2010 to June 30, 2016. The data was analysed with SPSS17.0 statistical package for windows.

RESULTS

A total of 1994 patients returned to PED within 24 hours from July 1, 2010 to June 30, 2016. The most common group of revisiting patients were toddlers (aged 0-2-year old), n=1168 (58.5%), and the least number represented young adolescents (aged 15-18-year old), n=82 (4.1%). Number of patients returning to PED in 24 hours has significantly increased within years from approximately 90 patients to 720 (p<0.05). This increase in number was observed in all and each age group (from 0-18 years of age) without any exception. Seasonal distribution of the patients showed no significant difference (p>0.05) for each age, but again, presented definite negative correlation with age (the older is the patient group, the less is the number of revisits). The most common time for revisits was 17-24 hours after first discharge from PED, n=1277 (64.04%).

CONCLUSION

The number of return visits is increasing over the years. The younger the patient is, more likely is the risk of unscheduled revisit to PED. Most of the patients returned to PED in 17 to 24 hours after discharge.

Emergency Department Return Visits Within a Large Geographic Area

BACKGROUND

Return visits to the emergency department (RTED) contribute to overcrowding and may be a quality of care indicator. Previous studies focused on factors predicting returns to and from the same center. Little is known about RTEDs across a range of community and specialty hospitals within a large geographic area.

OBJECTIVE

We sought to measure the frequency of pediatric RTEDs and describe their directional pattern across centers in a large catchment area.

METHODS

We conducted a multicenter, retrospective cross-sectional study of pediatric emergency visits in the Vancouver lower mainland within 1 year. Visits were linked across study sites, including one pediatric quaternary care referral center and 17 sites ranging from large regional centers to smaller community emergency departments (EDs). Returns were defined as subsequent visits to any site with a compatible diagnosis within 7 days of an index visit.

RESULTS

Among a total of 139,278 index ED visits by children, 12,133 (8.7% [95% confidence interval 8.6-8.9%]) were associated with 14,645 return visits to an ED. Three quarters of all index visits occurred at a general ED center, of which 8.9% had at least one RTED and 22% of these returns occurred at the pediatric ED (PED). Among PED index visits, 8.2% had at least one RTED and 13.6% of these returned to a general center. Overall, 38.9% of all RTEDs occurred at the PED. Multivariate regression did not identify any statistically significant association between ED crowding measures and likelihood of RTEDs.

CONCLUSIONS

Compared to single-center studies, this study linking hospitals within a large geographic area identified a higher proportion of RTEDs with a disproportionate burden on the PED.

Geography, Not Health System Affiliations, Determines Patients' Revisits to the Emergency Department

OBJECTIVES

To determine how frequently patients revisit the emergency department after an initial encounter, and to describe revisit capture rates for the same hospital, health system, and geographic region.

DATA SOURCES/STUDY SETTING

Florida state data from January 1, 2010, to June 30, 2011, from the Healthcare Cost and Utilization Project.

STUDY DESIGN

This is a retrospective cohort study of emergency department return visits among Florida adults over an 18-month period. We evaluated pairs of index and 30-day return emergency department visits and compared capture rates for hospital, health system, and geographic units.

DATA COLLECTION/EXTRACTION METHODS

Data were obtained from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project and the American Hospital Association Annual Survey Database.

PRINCIPAL FINDINGS

Among 9,416,212 emergency department visits, 22.6 percent (2,124,441) were associated with a 30-day return. Seventy percent (1,477,772) of 30-day returns occurred to the same hospital. The 30-day return capture rates were highest within the same geographic area: county-level capture at 92 percent (IQR=86-96 percent) versus health system capture at 75 percent (IQR = 68-81 percent).

CONCLUSIONS

Acute care utilization patterns are often independent of health system boundaries. Current population-based health care models that attribute patients to a single provider or health system may be strengthened by considering geographic patterns of acute care utilization.

Health Information Exchange: What do patients want?

To determine whether emergency department patients want to share their medical records across health systems through Health Information Exchange and if so, whether they prefer to sign consent or share their records automatically, 982 adult patients presenting to an emergency department participated in a questionnaire-based interview. The majority (N = 906; 92.3%) were willing to share their data in a Health Information Exchange. Half (N = 490; 49.9%) reported routinely getting healthcare outside the system and 78.6 percent reported having records in other systems. Of those who were willing to share their data in a Health Information Exchange, 54.3 percent wanted to sign consent but 90 percent of those would waive consent in the case of an emergency. Privacy and security were primary concerns of patients not willing to participate in Health Information Exchange and preferring to sign consent. Improved privacy and security protections could increase participation, and findings support consideration of "break-the-glass" provider access to Health Information Exchange records in an emergent situation.

Increased Identification of Emergency Department 72-hour Returns Using Multihospital Health Information Exchange

OBJECTIVES

Emergency departments (EDs) commonly analyze cases of patients returning within 72 hours of initial ED discharge as potential opportunities for quality improvement. In this study, we tested the use of a health information exchange (HIE) to improve identification of 72-hour return visits compared to individual hospitals' site-specific data.

METHODS

We collected deidentified patient data over a 5-year study period from Healthix, an HIE in the New York metropolitan area. We measured site-specific 72-hour ED returns and compared these data to those obtained from a regional 31-site HIE (Healthix) and to those from a smaller, antecedent 11-site HIE. Although only ED visits were counted as index visits, either ED or inpatient revisits within 72 hours of the index visit were considered as early returns.

RESULTS

A total of 12,669,657 patient encounters were analyzed across the 31 HIE EDs, including 6,352,829 encounters from the antecedent 11-site HIE. Site-specific 72-hour return visit rates ranged from 1.1% to 15.2% (median = 5.8%) among the individual 31 sites. When the larger HIE was used to identify return visits to any site, individual EDs had a 72-hour return frequency of 1.8% to 15.5% (median = 6.8%). HIE increased the identification ability of 72-hour ED return analyses by a mean of 11.16% (95% confidence interval = 11.10% to 11.22%) compared with site-specific (no HIE) analyses.

CONCLUSION

This analysis demonstrates incremental improvements in our ability to identify early ED returns using increasing levels of HIE data aggregation. Although intuitive, this has not been previously described using HIE. ED quality measurement and patient safety efforts may be aided by using HIE in 72-hour return analyses.

Understanding Emergency Department 72-Hour Revisits Among Medicaid Patients Using Electronic Healthcare Records

Electronic Healthcare Records (EHRs) have the potential to improve healthcare quality and to decrease costs by providing quality metrics, discovering actionable insights, and supporting decision-making to improve future outcomes. Within the United States Medicaid Program, rates of recidivism among emergency department (ED) patients serve as metrics of hospital performance that help ensure efficient and effective treatment within the ED. We analyze ED Medicaid patient data from 1,149,738 EHRs provided by a hospital over a 2-year period to understand the characteristics of the ED return visits within a 72-hour time frame. Frequent flyer patients with multiple revisits account for 47% of Medicaid patient revisits over this period. ED encounters by frequent flyer patients with prior 72-hour revisits in the last 6 months are thrice more likely to result in a readmit than those of infrequent patients. Statistical L1-logistic regression and random forest analyses reveal distinct patterns of ED usage and patient diagnoses between frequent and infrequent patient encounters, suggesting distinct opportunities for interventions to improve efficacy of care and streamline ED workflow. This work forms a foundation for future development of predictive models, which could flag patients at high risk of revisiting.