The Central Importance of Emergency Department Admission Rate Variation in Value-Based Care

Hospital-level variation in risk-standardized admission rates for emergency care-sensitive conditions among older and younger Veterans

OBJECTIVES

Research examining emergency department (ED) admission practices within the Department of Veterans Affairs (VA) is limited. This study investigates facility-level variation in risk-standardized admission rates (RSARs) for emergency care-sensitive conditions (ECSCs) among older (≥65 years) and younger (<65 years) Veterans across VA EDs.

METHODS

Veterans presenting to a VA ED for an ECSC between October 1, 2016 and September 30, 2019 were identified and the 10 most common ECSCs established. ECSC-specific RSARs were calculated using hierarchical generalized linear models, adjusting for Veteran and encounter characteristics. The interquartile range ratio (IQR ratio) and coefficient of variation were measures of dispersion for each condition and were stratified by age group. Associations with facility characteristics were also examined in condition-specific multivariable models.

RESULTS

The overall cohort included 651,336 ED visits across 110 VA facilities for the 10 most common ECSCs-chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, volume depletion, tachyarrhythmias, acute diabetes mellitus, gastrointestinal (GI) bleeding, asthma, sepsis, and myocardial infarction (MI). After adjusting for case mix, the ECSCs with the greatest variation (IQR ratio, coefficient of variation) in RSARs were asthma (1.43, 32.12), COPD (1.39, 24.64), volume depletion (1.38, 23.67), and acute diabetes mellitus (1.28, 17.52), whereas those with the least variation were MI (1.01, 0.87) and sepsis (1.02, 2.41). Condition-specific RSARs were not qualitatively different between age subgroups. Association with facility characteristics varied across ECSCs and within condition-specific age subgroups.

CONCLUSIONS

We identified unexplained facility-level variation in RSARs for Veterans presenting with the 10 most common ECSCs to VA EDs. The magnitude of variation did not appear to be qualitatively different between older and younger Veteran subgroups. Variation in RSARs for ECSCs may be an important target for systems-based levers to improve value in VA emergency care.

Emergency departments: The gatekeepers of admissions in Pennsylvania's rural hospitals

STUDY OBJECTIVE

To analyze trends in admission rates and the proportion of admissions via the ED at rural hospitals in Pennsylvania and to identify factors that may impact admission rates.

METHODS

We use retrospective, longitudinal data on rural acute care hospitals in Pennsylvania for 2000-19 to investigate temporal patterns in admission rates and the proportion of admissions via the ED. Regression analysis is then used to identify factors that may impact admission rates.

RESULTS

In general admission rates, which averaged 14.5%, experienced a gradual decline (Change: -16.9%; from 15.7% to 13%) between 2000 and 2019. The proportion of hospital admissions via the ED, which averaged 64.9%, increased steadily (21%; from 57% to 69%). Critical access hospitals experienced a sharp decline in admissions via the ED (-49.1%) and admission rates (-55.3%). The fixed-effects regression model revealed several hospital- and ED-level characteristics were significantly associated with admission rate.

CONCLUSIONS

Emergency departments are the gatekeepers of admissions at rural acute care hospitals in Pennsylvania. Many hospitals in rural Pennsylvania, including CAHs, are admitting most of their patients through the ED, concomitant with a significant decline in admissions and admission rates. This highlights the need to strengthen primary care practices serving rural Pennsylvania as well as the need to improve rural emergency and trauma systems. In the short to medium term, policy makers should explore innovative ways to fund smaller hospitals, especially CAHs, to develop level IV trauma center capabilities.