Alternative Dispositions for Emergency Department Patients

Association Between In-Person vs Telehealth Follow-up and Rates of Repeated Hospital Visits Among Patients Seen in the Emergency Department

Importance

For patients discharged from the emergency department (ED), timely outpatient in-person follow-up is associated with improved mortality, but the effectiveness of telehealth as follow-up modality is unknown.

Objective

To evaluate whether the rates of ED return visits and hospitalization differ between patients who obtain in-person vs telehealth encounters for post-ED follow-up care.

Design, Setting, and Participants

This retrospective cohort study included adult patients who presented to either of 2 in-system EDs of a single integrated urban academic health system from April 1, 2020, to September 30, 2021; were discharged home; and obtained a follow-up appointment with a primary care physician within 14 days of their index ED visit (15 total days).

Exposures

In-person vs telehealth post-ED discharge follow-up within 14 days.

Main Outcomes and Measures

Multivariable logistic regression was used to estimate the odds of ED return visits (primary outcome) or hospitalization (secondary outcome) within 30 days of an ED visit based on the modality of post-ED discharge follow-up. Models were adjusted for age, sex, primary language, race, ethnicity, Social Vulnerability Index, insurance type, distance to the ED, ambulatory billing codes for the index visit, and the time from ED discharge to follow-up.

Results

Overall, 12 848 patients with 16 987 ED encounters (mean [SD] age, 53 [20] years; 9714 [57%] women; 2009 [12%] Black or African American; 3806 [22%] Hispanic or Latinx; and 9858 [58%] White) were included; 11 818 (70%) obtained in-person follow-up, and 5169 (30%) obtained telehealth follow-up. Overall, 2802 initial ED encounters (17%) led to returns to the ED, and 676 (4%) led to subsequent hospitalization. In adjusted analyses, telehealth vs in-person follow-up visits were associated with increased rates of ED returns (28.3 [95% CI, 11.3-45.3] more ED returns per 1000 encounters) and hospitalizations (10.6 [95% CI, 2.9-18.3] more hospitalizations per 1000 encounters).

Conclusions and Relevance

In this cohort study of patients in an urban integrated health care system, those with telehealth follow-up visits after an ED encounter were more likely to return to the ED and be hospitalized than patients with in-person follow-up. The use of telehealth warrants further evaluation to examine its effectiveness as a modality for continuing care after an initial ED presentation for acute illness.

Receipt of Telepsychiatry and Emergency Department Visit Outcomes in New York State

Telepsychiatry has made psychiatric care more accessible to emergency department (ED) patients. To date, most telepsychiatry studies have focused on specific populations or small groups of EDs. This study sought to examine the potential role of telepsychiatry across a wider range of EDs by comparing visit dispositions for psychiatric visits in EDs that did (versus did not) receive telepsychiatry services. ED telepsychiatry service status was identified from the 2016 National ED Inventory-USA and then linked to psychiatric visits from the 2016 New York State Emergency Department Databases/State Inpatient Databases. Unadjusted analyses and multivariable logistic regression models were used to evaluate associations between an ED's telepsychiatry service status and two clinical outcomes: use of observation services and ED visit disposition. Across all psychiatric ED visits, 712,236 were in EDs without telepsychiatry while 101,025 were in EDs with telepsychiatry. Most (99.8%) visits were in urban EDs. In multivariable logistic regression models, psychiatric visits in EDs with telepsychiatry services had lower odds (adjusted odds ratio 0.30) of using observation services compared to visits in EDs without telepsychiatry. The receipt of ED telepsychiatry is associated with lower usage of observation services for psychiatric visits, likely reducing the amount of time spent in the ED and mitigating the ongoing problem of ED crowding. An overwhelming majority of visits in EDs with telepsychiatry services were in urban hospitals with existing psychiatric services. Factors affecting the delivery and effectiveness of telepsychiatry services to hospitals lacking in psychiatric resources merit further investigation.

Practical alternative to hospitalization for emergency department patients (PATH): A feasibility study

OBJECTIVE

We sought to determine the feasibility of the Practical Alternative to Hospitalization (PATH) program, an intervention that offers ED clinicians an outpatient care pathway for patients initially designated for inpatient admission or observation.

METHODS

We evaluated a novel care delivery model that was piloted at a tertiary academic medical center in December 2019. An advanced practice provider screened patients designated for inpatient admission or observation and identified eligible participants. Outpatient services were customized for each patient but primarily included care coordination and monitoring through telemedicine and home health services. The primary feasibility outcome was the proportion of eligible patients who were enrolled in the program, as well as patient outcomes after discharge including return ED visits and averted ED boarding time.

RESULTS

A total of 199 patients were designated for inpatient admission or observation during PATH program hours. Of 52 eligible patients, 30 (58%) were enrolled. The mean participant age was 62.5 years (SD 17.5), and 25 (83%) had non-Hispanic Black race/ethnicity. The most common disease conditions were chest pain, heart failure, and hyperglycemia. 4 (13%) enrolled patients returned to an ED within 30 days. We estimate that ED boarding time was reduced by 8.2 h (SD 8.1) per patient.

CONCLUSION

Emergency physicians and patients were willing to use a novel service that provided an alternative disposition to hospitalization.

IMPLICATIONS

alternative payment models that seek to reduce hospital utilization and cost may consider strengthening systems to monitor and coordinate care for patients after ED discharge.