Early death after discharge from emergency departments: analysis of national US insurance claims data

Reliability of a Measure of Admission Intensity for Emergency Physicians

STUDY OBJECTIVE

We assess the stability of a measure of emergency department (ED) admission intensity for value-based care programs designed to reduce variation in ED admission rates. Measure stability is important to accurately assess admission rates across sites and among physicians.

METHODS

We sampled data from 358 EDs in 41 states (January 2018 to December 2021), separate from sites where the measure was derived. The measure is the ED admission rate per 100 ED visits for 16 clinical conditions and 535 included International Classification of Disease 10 diagnosis codes. We used descriptive plots and multilevel linear probability models to assess stability over time across EDs and among physicians.

RESULTS

Across included 3,571 ED-quarters, the average admission rate was 27.6% (95% confidence interval [CI] 26.0% to 28.2%). The between-facility standard deviation was 9.7% (95% CI 9.0% to 10.6%), and the within-facility standard deviation was 3.0% (95% CI 2.95% to 3.10%), with an intraclass correlation coefficient of 0.91. At the physician-quarter level, the average admission rate was 28.3% (95% CI 28.0% to 28.5%) among 7,002 physicians. Relative to their site's mean in each quarter, the between-physician standard deviation was 6.7% (95% CI 6.6% to 6.8%), and the within-physician standard deviation was 5.5% (95% CI 5.5% to 5.6%), with an intraclass correlation coefficient of 0.59. Moreover, 2.9% of physicians were high-admitting in 80%+ of their practice quarters relative to their peers in the same ED and in the same quarter, whereas 3.9% were low-admitting.

CONCLUSION

The measure exhibits stability in characterizing ED-level admission rates and reliably identifies high- and low-admitting physicians.

Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients

STUDY OBJECTIVE

Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients.

METHODS

We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3).

RESULTS

For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill.

CONCLUSION

We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.

Trends in observation stays for Medicare beneficiaries with and without Alzheimer's disease and related dementias

BACKGROUND

There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) is unknown.

METHODS

Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH-), no AD/ADRD residing in NH (AD/ADRD- NH+), and no AD/ADRD not residing in NH (AD/ADRD- NH-).

RESULTS

Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77-0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59-0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD- NH- population, but the AD/ADRD+ NH- group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0-15.7).

CONCLUSIONS

Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation.

Acute patients discharged without an established diagnosis: risk of mortality and readmission of nonspecific diagnoses compared to disease-specific diagnoses

BACKGROUND

Nonspecific discharge diagnoses after acute hospital courses represent patients discharged without an established cause of their complaints. These patients should have a low risk of adverse outcomes as serious conditions should have been ruled out. We aimed to investigate the mortality and readmissions following nonspecific discharge diagnoses compared to disease-specific diagnoses and assessed different nonspecific subgroups.

METHODS

Register-based cohort study including hospital courses beginning in emergency departments across 3 regions of Denmark during March 2019-February 2020. We identified nonspecific diagnoses from the R- and Z03-chapter in the ICD-10 classification and excluded injuries, among others-remaining diagnoses were considered disease-specific. Outcomes were 30-day mortality and readmission, the groups were compared by Cox regression hazard ratios (HR), unadjusted and adjusted for socioeconomics, comorbidity, administrative information and laboratory results. We stratified into short (3-<12 h) or lengthier (12-168 h) hospital courses.

RESULTS

We included 192,185 hospital courses where nonspecific discharge diagnoses accounted for 50.7% of short and 25.9% of lengthier discharges. The cumulative risk of mortality for nonspecific vs. disease-specific discharge diagnoses was 0.6% (0.6-0.7%) vs. 0.8% (0.7-0.9%) after short and 1.6% (1.5-1.7%) vs. 2.6% (2.5-2.7%) after lengthier courses with adjusted HRs of 0.97 (0.83-1.13) and 0.94 (0.85-1.05), respectively. The cumulative risk of readmission for nonspecific vs. disease-specific discharge diagnoses was 7.3% (7.1-7.5%) vs. 8.4% (8.2-8.6%) after short and 11.1% (10.8-11.5%) vs. 13.7% (13.4-13.9%) after lengthier courses with adjusted HRs of 0.94 (0.90-0.98) and 0.95 (0.91-0.99), respectively. We identified 50 clinical subgroups of nonspecific diagnoses, of which Abdominal pain (n = 12,462; 17.1%) and Chest pain (n = 9,599; 13.1%) were the most frequent. The subgroups described differences in characteristics with mean age 41.9 to 80.8 years and mean length of stay 7.1 to 59.5 h, and outcomes with < 0.2-8.1% risk of 30-day mortality and 3.5-22.6% risk of 30-day readmission.

CONCLUSIONS

In unadjusted analyses, nonspecific diagnoses had a lower risk of mortality and readmission than disease-specific diagnoses but had a similar risk after adjustments. We identified 509 clinical subgroups of nonspecific diagnoses with vastly different characteristics and prognosis.

Machine learning in clinical practice: Evaluation of an artificial intelligence tool after implementation

OBJECTIVE

Artificial intelligence (AI) has gradually found its way into healthcare, and its future integration into clinical practice is inevitable. In the present study, we evaluate the accuracy of a novel AI algorithm designed to predict admission based on a triage note after clinical implementation. This is the first of such studies to investigate real-time AI performance in the emergency setting.

METHODS

The novel AI algorithm that predicts admission using a triage note was translated into clinical practice and integrated within St Vincent's Hospital Melbourne's electronic emergency patient management system. The data were collected from 1 January 2021 to 17 August 2022 to evaluate the diagnostic accuracy of the AI system after implementation.

RESULTS

A total of 77 125 ED presentations were included. The live AI algorithm has a sensitivity of 73.1% (95% confidence interval 72.5-73.8), specificity of 74.3% (73.9-74.7), positive predictive value of 50% (49.6-50.4) and negative predictive value of 88.7% (88.5-89) with a total accuracy of 74% (73.7-74.3). The accuracy of the system was at the lowest for admission to psychiatric units (34%) and at the highest for gastroenterology and medical admission (84% and 80%, respectively).

CONCLUSION

Our study showed the diagnostic evaluation of a real-time AI clinical decision-support tool became less accurate than the original. Although real-time sensitivity and specificity of the AI tool was still acceptable as a decision-support tool in the ED, we propose that continuous training and evaluation of AI-enabled clinical support tools in healthcare are conducted to ensure consistent accuracy and performance to prevent inadvertent consequences.

A fast emergency department triage score based on mobility, mental status and oxygen saturation compared with the emergency severity index: a prospective cohort study

BACKGROUND

Waiting for triage in overburdened emergency departments (ED) has become an increasing problem, which endangers patients. A fast triage system to rapidly identify low-acuity patients should divert care and resources to more urgent cases.

AIM

The objective of this study was to compare the performance of the Kitovu Hospital fast triage (KFT) score with the Emergency Severity Index (ESI), using mortality and hospital admission as proxies for the patients' acuity.

DESIGN

This is a prospective observational study of consecutive patients presenting to a Swiss academic ED.

METHODS

Patients were prospectively triaged into one of five ESI strata and retrospectively assessed by the KFT score, which awards one point each for altered mental status, impaired mobility and oxygen saturation <94%.

RESULTS

The KFT score had a lower discrimination than the ESI for hospital admission, but a higher discrimination for mortality from 24 h to 1 year after ED presentation. A total of 5544 (67%) patients were assigned to the lowest acuity by the KFT score compared with 2374 (28.7%) by the ESI; there was no significant difference in the 24-h mortality of patients who were deemed low acuity by either score.

CONCLUSION

Compared to the ESI, the KFT score identifies more than twice as many patients at low risk of early death. Therefore, this score might help to identify patients who could be managed through alternative pathways. This may be particularly helpful in situations of ED crowding and access block.

Trends in healthy days at home for Medicare beneficiaries using the emergency department

BACKGROUND

Older adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility-based healthcare settings versus home. We examined trends in 30-day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status.

METHODS

We identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30-day HDAH by subtracting mortality days and days spent in facility-based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status.

RESULTS

We found fewer adjusted 30-day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long-term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30-day HDAH for beneficiaries with and without AD/ADRD.

CONCLUSIONS

Beneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post-acute care.

Association Between Emergency Physician's Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit

STUDY OBJECTIVE

To determine the association between emergency physicians' ages and patient mortality after emergency department visits.

METHODS

This observational study used a 20% random sample of Medicare fee-for-service beneficiaries aged 65 to 89 years treated by emergency physicians at EDs from 2016 to 2017. We investigated whether 7-day mortality after ED visits differed by the age of the emergency physician, adjusting for patient and physician characteristics and hospital fixed effects.

RESULTS

We observed 2,629,464 ED visits treated by 32,570 emergency physicians (mean age 43.5). We found that patients treated by younger emergency physicians had lower mortality rates compared with those treated by older physicians. Adjusted 7-day mortality was 1.33% for patients treated by emergency physicians aged less than 40 years, 1.36% (adjusted difference, 0.03%; 95% confidence interval [CI], -0.001% to 0.06%) for physicians ages 40 to 49, 1.40% (0.08%; 95% CI 0.04% to 0.12%) for physicians ages 50 to 59, and 1.43% (0.11%; 95% CI 0.06% to 0.16%) for those with a physician age of 60 years and more. Similar patterns were observed when stratified by the patient's disposition (discharged vs admitted), and the association was more pronounced for patients with higher severity of illness.

CONCLUSIONS

Medicare patients aged 65 to 89 years treated by emergency physicians aged under 40 years had lower 7-day mortality rates than those treated by physicians aged 50 to 59 years and 60 years or older within the same hospital. Potential mechanisms explaining the association between emergency physician age and patient mortality (eg, differences in training received and other unobservable patient/physician characteristics) are uncertain and require further study.

The prediction of 24-h mortality by the respiratory rate and oxygenation index compared with National Early Warning Score in emergency department patients: an observational study

BACKGROUND

The ROX index combines respiratory rate and oxygenation to predict the response to oxygen therapy in pneumonia. It is calculated by dividing the patient's oxygen saturation, by the inspired oxygen concentration, and then by the respiratory rate (e.g. 95%/0.21/16 = 28). Since this index includes the most essential physiological variables to detect deterioration, it may be a helpful risk tool in the emergency department (ED). Although small studies suggest it can predict early mortality, no large study has compared it with the National Early Warning Score (NEWS), the most widely validated risk score for death within 24 h.

AIM

The aim of this study was to compare the ability of the ROX index with the NEWS to predict mortality within 24 h of arrival at the hospital.

METHODS

This was a retrospective observational multicentre analysis of data in the Netherlands Emergency Department Evaluation Database (NEED) on 270 665 patients attending four participating Dutch EDs. The ROX index and NEWS were determined on ED arrival and prior to ED treatment.

RESULTS

The risk of death within 24 h increased with falling ROX and rising NEWS values. The area under the receiving operating characteristic curves for 24-h mortality of NEWS was significantly higher than for the ROX index [0.92; 95% confidence interval (CI), 0.91-0.92 versus 0.87; 95% CI, 0.86-0.88; P  < 0.01]. However, the observed and predicted mortality by the ROX index was identical to mortality of 5%, after which mortality was underestimated. In contrast, up to a predicted 24-h mortality of 3% NEWS slightly underestimates mortality, and above this level over-estimates it. The standardized net benefit of ROX is slightly higher than NEWS up to a predicted 24-h mortality of 3%.

CONCLUSION

The prediction of 24-h mortality by the ROX index is more accurate than NEWS for most patients likely to be encountered in the ED. ROX may be used as a first screening tool in the ED.

Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare

Importance

Medicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for ambulatory care-sensitive conditions (ACSCs). However, it remains unknown whether Medicare Advantage plans lower acute care use compared with traditional Medicare, or if it shifts patients from hospitalization to observation stays and emergency department (ED) direct discharges.

Objective

To determine whether Medicare Advantage is associated with differential utilization of hospitalizations, observations, and ED direct discharges for ACSCs compared with traditional Medicare.

Design, Setting, and Participants

Cross-sectional study of US Medicare Advantage vs traditional Medicare beneficiaries from January 1 to December 31, 2018. Poisson regression models were used to compare risk-adjusted rates of Medicare Advantage vs traditional Medicare, controlling for patient demographic characteristics and clinical risk and including county fixed-effects. Data were analyzed between April 2021 and November 2022.

Main Outcomes and Measures

Hospitalizations, observation stays, and ED direct discharges for ACSCs.

Results

The study sample comprised 2 665 340 Medicare Advantage patients (mean [SD] age, 72.7 [9.8] years; 1 504 519 [56.4%] women; 1 859 067 [69.7%] White individuals) and 7 981 547 traditional Medicare patients (mean [SD] age, 71.2 [11.8] years; 4 232 201 [53.0%] women; 6 176 239 [77.4%] White individuals). Medicare Advantage patients had lower risk of hospitalization for ACSCs compared with traditional Medicare patients (relative risk [RR], 0.94; 95% CI, 0.93-0.95), primarily owing to fewer hospitalizations for acute conditions (eg, pneumonia). Medicare Advantage patients had a higher risk of ED direct discharges (RR, 1.44; 95% CI, 1.43-1.45) and observation stays (RR, 2.38; 95% CI, 2.34-2.41) for ACSCs vs traditional Medicare patients. Overall, Medicare Advantage patients were at higher risk of needing care for an ACSC (hospitalization, ED direct discharge, or observation stay) than traditional Medicare patients (RR, 1.30; 95% CI, 1.30-1.31). Within the Medicare Advantage population, patients in health maintenance organizations (HMOs) were at lower risk of ACSC-related hospitalization compared with patients in its preferred provider organizations (RR, 0.96; 95% CI, 0.95-0.98); however, those in the HMOs had a higher risk of ED direct discharge (RR, 1.08; 95% CI, 1.07-1.09) and observation stay (overall RR, 1.10; 95% CI, 1.02-1.12).

Conclusions and Relevance

The findings of this cross-sectional study of Medicare Advantage and traditional Medicare patients with ACSCs indicate that apparent gains in lowering rates of potentially avoidable acute care have been associated with shifting inpatient care to settings such as ED direct discharges and observation stays.

Factors Associated with Anticoagulation Initiation for New Atrial Fibrillation in an Urban Emergency Department

Objective

To explore factors associated with anticoagulation (AC) initiation after atrial fibrillation (AF) diagnosis.

Design

Retrospective cohort study.

Setting

Urban medical center.

Patients

Adults with emergency department (ED) diagnosis of new onset AF from 1/1/2017-1/1/2020 discharged home.

Methods

We compared patients initiated on AC, our primary outcome, to those not initiated on AC. Stroke, major bleeding, and AC initiation within 1 year of visit were secondary outcomes. We hypothesized that minority race and non-English language preference are associated with failure to initiate AC.

Results

Of 111 patients with AF, 88 met inclusion criteria. Mean age was 65 (SD 15); 47 (53%) were women. 49 (56%) patients were initiated on AC. Age (61 vs 68 years; P=.02), non-English language (28% vs 10%; P=.03), leaving ED against medical advice (AMA) (36% vs 14%; P=.04), and CHA²DS²-VASc score of 1 (41% vs 6%; P<=.001) were associated with no AC initiation. There were no associations between patient-reported race/ethnicity and AC. Cardiology consultation (83.67% vs 30.78%; P<.0001) and higher median CHA²DS²-VASc score (3[2-4]) vs. 2[1-4]; P=.047) were associated with AC. Of 73 patients with follow-up data at 1 year, 2 (8%) not initiated on AC had strokes, 2 (4%) initiated on AC had major bleeds, and 15 (62.5%) not initiated on AC in the ED subsequently were initiated on AC.

Conclusion

More than half of ED patients with new AF eligible for AC were initiated on it. Work to improve AC utilization among patients with new AF who left AMA from ED and those who prefer to communicate in a non-English language may be warranted.

An explanatory machine learning framework for studying pandemics: The case of COVID-19 emergency department readmissions

One of the major challenges that confront medical experts during a pandemic is the time required to identify and validate the risk factors of the novel disease and to develop an effective treatment protocol. Traditionally, this process involves numerous clinical trials that may take up to several years, during which strict preventive measures must be in place to control the outbreak and reduce the deaths. Advanced data analytics techniques, however, can be leveraged to guide and speed up this process. In this study, we combine evolutionary search algorithms, deep learning, and advanced model interpretation methods to develop a holistic exploratory-predictive-explanatory machine learning framework that can assist clinical decision-makers in reacting to the challenges of a pandemic in a timely manner. The proposed framework is showcased in studying emergency department (ED) readmissions of COVID-19 patients using ED visits from a real-world electronic health records database. After an exploratory feature selection phase using genetic algorithm, we develop and train a deep artificial neural network to predict early (i.e., 7-day) readmissions (AUC = 0.883). Lastly, a SHAP model is formulated to estimate additive Shapley values (i.e., importance scores) of the features and to interpret the magnitude and direction of their effects. The findings are mostly in line with those reported by lengthy and expensive clinical trial studies.

Racial Disparities in Hospitalization Among Patients Who Receive a Diagnosis of Acute Coronary Syndrome in the Emergency Department

Background Timely hospitalization of patients who are diagnosed with an acute coronary syndrome (ACS) at the emergency department (ED) is a crucial step to lower the risk of ACS mortality. We examined whether there are racial and ethnic differences in the risk of being discharged home among patients who received a diagnostic code of ACS at the ED and whether having health insurance plays a role. Methods and Results We examined 51 022 910 discharge records of ED visits in Florida, New York, and Utah in the years 2008, 2011, 2014, and 2016/2017 using state-specific data from the Healthcare Cost and Utilization Project. We identified ED admissions for acute myocardial infarction or unstable angina using the International Classification of Diseases, Ninth Revision (ICD-9)/International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes. We used generalized estimating equation models to compare the risk of being discharged home across racial and ethnic groups. We used Poisson marginal structural models to estimate the mediating role of health insurance status. The proportion discharged home with a diagnostic code of ACS was 12% among Black patients, 6% among White patients, 9% among Hispanic patients, and 9% among Asian/Pacific Islander patients. The incidence risk ratio for being discharged home was 1.26 (95% CI, 1.18-1.34) in Black patients, 1.23 (95% CI, 1.15-1.32) in Hispanic patients, and 1.11 (95% CI, 0.93-1.31) in Asian/Pacific Islander patients compared with White patients. Race and ethnicity were marginally associated with discharge home via pathways not mediated by health insurance. Conclusions Racial and ethnic disparities exist in the hospitalization of patients who received a diagnostic code of ACS in the ED. Possible causes need to be investigated.

Factors Associated with Emergency Department Visits and Consequent Hospitalization and Death in Korea Using a Population-Based National Health Database

We aim to investigate common diagnoses and risk factors for emergency department (ED) visits as well as those for hospitalization and death after ED visits. This study describes the clinical course of ED visits by using the 2014–2015 population data retrieved from the National Health Insurance Service. Sociodemographic, medical, and behavioral factors were analyzed through multiple logistic regression. Older people were more likely to be hospitalized or to die after an ED visit, but younger people showed a higher risk for ED visits. Females were at a higher risk for ED visits, but males were at a higher risk for ED-associated hospitalization and death. Individuals in the highest quartile of income had a lower risk of ED death relative to lowest income level individuals. Disabilities, comorbidities, and medical issues, including previous ED visits or prior hospitalizations, were risk factors for all ED-related outcomes. Unhealthy behaviors, including current smoking, heavy alcohol consumption, and not engaging in regular exercise, were also significantly associated with ED visits, hospitalization, and death. Common diagnoses and risk factors for ED visits and post-visit hospitalization and death found in this study provide a perspective from which to establish health polices for the emergency medical care system.

Modified Shock Index as a Predictor for Mortality and Hospitalization Among Patients With Dementia

BACKGROUND

One in four older adults in the Emergency Department (ED) suffers from severe cognitive impairment, creating great difficulty for the emergency physicians who determine the urgency of their patients' condition, which informs decisions regarding discharge or hospitalization.

OBJECTIVE

Our objective was to determine whether modified shock index (MSI) can be a clinical mortality and hospitalization predictor when applied to older patients with dementia in the ED.

METHODS

Included in the research were all patients with dementia, > 65 years old, who arrived at the Soroka University Medical Center ED during 2014-2017. The population was divided into three groups according to their MSI score, calculated as heart rate/mean arterial pressure: MSI < 0.7; 0.7 > MSI < 1.3; and MSI > 1.3. We performed multivariable logistic regression as a predictor of death within 30 days, Cox analysis for number of days to death, and a negative binominal regression for predicting the number of admission days.

RESULTS

Included were 1437 patients diagnosed with dementia. Patients with an MSI > 1.3 vs. those with MSI < 0.7 had an odds ratio of 8.23 (95% confidence interval [CI] 4.64-4.54) for mortality within 30 days, increased mortality risk within 180 days (hazard ratio 4.42; 95% CI 2.64-7.41), and longer hospitalization duration (incidence rate ratio 1.8; 95% CI 1.32-2.45).

CONCLUSIONS

High MSI scores were associated with high mortality rates and longer hospitalization duration for patients diagnosed with dementia who were > 65 years old. We suggest performing prospective studies utilizing the MSI score as an indicator in ED triage settings to classify patients with dementia by their severity of risk, to determine if this benefits health, minimizes expenses, and prevents unnecessary hospitalizations.

A longitudinal, retrospective registry-based validation study of RETTS©, the Swedish adult ED context version

BACKGROUND

Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. The Rapid Emergency Triage and Treatment System (RETTS©), with annual updates, is the most applied triage system. However, the national implementation has been performed despite low scientific foundation for triage as a method, mainly related to the absence of adjustment to age and gender. Furthermore, there is a lack of studies of RETTS© in Swedish ED context, especially of RETTS© validity. Hence, the aim the study was to determine the validity of RETTS©.

METHODS

A longitudinal retrospective register study based on cohort data from a healthcare region comprising two EDs in southern Sweden. Two editions of RETTS© was selected; year 2013 and 2016, enabling comparison of crude data, and adjusted for age-combined Charlson comorbidity index (ACCI) and gender. All patients ≥ 18 years visiting either of the two EDs seeing a physician, was included. Primary outcome was ten-day mortality, secondary outcome was admission to Intensive Care Unit (ICU). The data was analysed with descriptive, and inferential statistics.

RESULTS

Totally 74,845 patients were included. There was an increase in patients allocated red or orange triage levels (unstable) between the years, but a decrease of admission, both to general ward and ICU. Of all patients, 1031 (1.4%) died within ten-days. Both cohorts demonstrated a statistically significant difference between the triage levels, i.e. a higher risk for ten-day mortality and ICU admission for patients in all triage levels compared to those in green triage level. Furthermore, significant statistically differences were demonstrated for ICU admission, crude as well as adjusted, and for adjusted data ten-day mortality, indicating that ACCI explained ten-day mortality, but not ICU admission. However, no statistically significant difference was found for the two annual editions of RETTS© considering ten-day mortality, crude data.

CONCLUSION

The annual upgrade of RETTS© had no statistically significant impact on the validity of the triage system, considering the risk for ten-day mortality. However, the inclusion of ACCI, or at least age, can improve the validity of the triage system.

How do we identify acute medical admissions that are suitable for same day emergency care?

Medical emergencies causing unplanned hospital admission place considerable demands on acute healthcare services. Some patients can be assessed and treated through ambulatory pathways without inpatient admission, via same day emergency care (SDEC), potentially benefiting patients and reducing demands on inpatient services. There is currently considerable variation within acute medicine in aspects of SDEC delivery ranging from overall service design to patient selection methods. Scoring systems identifying patients likely to be successfully managed through SDEC services have been suggested, but evidence of utility in diverse populations is lacking. Specific scoring systems exist for some common medical problems, including cardiac chest pain and pulmonary embolism, but further research is needed to demonstrate how these are most effectively incorporated into SDEC services. This review defines SDEC and describes the variation in services nationally. It reviews the evidence for their clinical impact, tools to screen patients for SDEC and current gaps in our knowledge regarding service deployment.

Profiling Bispebjerg Acute Cohort: Database Formation, Acute Contact Characteristics of a Metropolitan Hospital, and Comparisons to Urban and Rural Hospitals in Denmark

Purpose

To present a metropolitan cohort, Bispebjerg acute cohort (BAC), and compare patient characteristics and outcomes with patients from urban and rural hospitals in Denmark.

Patients and Methods

We linked data from seven Danish nationwide registries and included all acute contacts to non-psychiatric hospitals in the years 2016–2018. Acute hospital contacts to Bispebjerg and Frederiksberg Hospital constituted BAC, representing a solely metropolitan/urban catchment area. Patient characteristics and outcomes were compared to the rest of Denmark in an urban cohort (UrC) and a rural cohort (RuC), stratified by visit and hospitalization contact types.

Results

We identified 4,063,420 acute hospital contacts in Denmark and BAC constituted 8.4% (n=343,200) of them. BAC had a higher proportion of visits (65.1%) compared with UrC (52.1%) and RuC (45.3%). Patients in BAC more often lived alone (visits: BAC: 34.8%, UrC: 30.6%, RuC: 29.2%; hospitalizations: BAC: 50.8%, UrC: 36.7%, RuC: 37.2%) and had temporary CPR number (visits: BAC: 4.4%, UrC: 1.9%, RuC: 1.6%; hospitalizations: BAC: 1.5%, UrC: 0.9%, RuC: 0.8%). Visit patients in BAC were younger (BAC: 36, UrC: 42, RuC: 45 years, median), more often students (BAC: 18.0%, UrC: 14.0%, RuC: 12.5%), and had more contacts due to infectious diseases (BAC: 19.8%, UrC: 14.1%, RuC: 6.2%) but less due to injuries (BAC: 40.0%, UrC: 43.8%, RuC: 60.7%). Hospitalized patients in BAC had higher median age (BAC: 64, UrC: 61, RuC: 64 years) and fewer were in employment than in UrC (BAC: 26.1%, UrC: 32.1%, RuC: 28.1%). BAC Hospitalizations had a lower death rate within 30 days than in RuC (BAC: 3.0% [2.9–3.1%], UrC: 3.1% [3.0–3.1%], RuC: 3.4% [3.3–3.4%]), but a higher readmission-rate (BAC: 20.5% [20.3–20.8%], UrC: 17.3% [17.2–17.4%], RuC: 17.5% [17.5–17.6%]).

Conclusion

Significant differences between BAC, urban, and rural cohorts may be explained by differences in healthcare structure and sociodemographics of the catchment areas.

Evaluation and disposition of older adults presenting to the emergency department with abdominal pain

BACKGROUND

Abdominal pain is the most common chief complaint in US emergency departments (EDs) among patients over 65, who are at high risk of mortality or incident disability after the ED encounter. We sought to characterize the evaluation, management, and disposition of older adults who present to the ED with abdominal pain.

METHODS

We performed a survey-weighted analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), comparing older adults with a chief complaint of abdominal pain to those without. Visits from 2013 to 2017 to nationally representative EDs were included. We analyzed 81,509 visits to 1211 US EDs, which projects to 531,780,629 ED visits after survey weighting. We report the diagnostic testing, evaluation, management, additional reasons for visit, and disposition of ED visits.

RESULTS

Among older adults (≥65 years), 7% of ED visits were for abdominal pain. Older patients with abdominal pain had a lower probability of being triaged to the "Emergent" (ESI2) acuity on arrival (7.1% vs. 14.8%) yet were more likely to be admitted directly to the operating room than older adults without abdominal pain (3.6% vs. 0.8%), with no statistically significant differences in discharge home, death, or admission to critical care. Ultrasound or CT imaging was performed in 60% of older adults with abdominal pain. A minority (39%) of older patients with abdominal pain received an electrocardiogram (EKG).

CONCLUSIONS

Abdominal pain in older adults presenting to EDs is a serious condition yet is triaged to "emergent" acuity at half the rate of other conditions. Opportunities for improving diagnosis and management may exist. Further research is needed to examine whether improved recognition of abdominal pain as a syndromic presentation would improve patient outcomes.

Validation of a Simple Score for Mortality Prediction in a Cohort of Unselected Emergency Patients

BACKGROUND

Prognostication is an important component of medical decision-making. A patients' general prognosis can be difficult to measure. The Simple Prognostic Score (SPS) was designed to include patients' age, mobility, aggregated vital signs, and the treating physician's decision to admit to aid prognostication. Study Aim. Our study aim is to validate the SPS, compare it with the Emergency Severity Index (ESI) regarding its prognostic performance, and test the interrater reliability of the subjective variable of the decision to admit.

METHODS

Over a period of 9 weeks all patients presenting to the ED were included, routinely interviewed, final disposition registered, and followed up for one year. The C-statistics of discrimination was used to compare SPS and ESI predictions of 7-day, 30-day, and 1-year mortality. Youden J Statistics and Odds ratio, using logistical regression, were calculated for the Simple Prognostic Score. In a subset, a chart review was performed by senior physicians for a secondary assessment of the decision to admit. Interrater reliability was calculated using percentages and Cohens Kappa.

RESULTS

Out of 5648 patients, 3272 (57.9%) had a low SPS (i.e., ≤ 1); none of these patients died within 7 days, 2 (0.1%) died within 30 days after presentation and 19 (0.6%) died within a year. The area under the curve for 1-year mortality of the Simple Prognostic Score was 0.848. Secondary analysis of the interrater agreement for the decision to admit was 92%.

CONCLUSION

In a prospective study of unselected ED patients, the Simple Prognostic Score was validated as a reliable predictor of short- and long-term mortality.

Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries

IMPORTANCE

Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs).

OBJECTIVE

To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization.

RESULTS

The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.

Remember that patient you saw last week: characteristics and frequency of patients experiencing anticipated and unanticipated death following ED discharge

BACKGROUND

The emergency department (ED) is an at-risk area for medical error. We determined the characteristics of patients with unanticipated and anticipated death within 7 days of ED discharge and whether medical error contributed.

METHODS

We performed a single-centre health records review of 200 consecutive cases during a 3-year period from 2014 to 2017 in two urban, academic, tertiary care EDs. We included patients evaluated by an emergency physician who were discharged and died within 7 days. Three trained and blinded reviewers determined if deaths were related to the index visit, anticipated or unanticipated, and/or due to potential medical error. Reviewers performed content analysis to identify themes.

RESULTS

Of 200 cases, 129 had sufficient information for analysis, translating to 44 deaths per 100,000 ED discharges (200/458,634). 13 cases per 100,000 ED discharges (58/458,634) were related and unanticipated deaths. 4 cases per 100,000 were due to potential medical errors (18/458,634). Over half (52.7%) of 129 patients displayed abnormal vital signs at discharge. Pneumonia (27.1%) was the most common cause of death. Patient themes were: difficult historian, multiple complaints, multiple comorbidities, acute progression of chronic disease, and recurrent falls. Provider themes were: failure to consider infectious etiology, failure to admit high-risk elderly patient, and missed diagnosis. System themes were: multiple ED visits or recent admission, and no repeat vital signs recorded.

CONCLUSION

Though the frequency of related and unanticipated deaths and those due to medical error was low, clinicians should carefully consider the highlighted common patient, provider, and system themes to facilitate safe discharge from the ED.

Inpatient Outcomes Following a Return Visit to the Emergency Department: A Nationwide Cohort Study

Introduction

Emergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database.

Methods

This was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit.

Results

Of the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72–0.84), and lower costs (adjusted difference, −5,198 New Taiwan dollars, 95% CI, −6,224 to −4,172).

Conclusion

Patients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.

Interventions for the discharge of older people to their home from the emergency department: a systematic review

BACKGROUND

Clinicians have limited evidence on which to base their practice to effectively discharge older people from emergency. The aim of the review was to assess the effectiveness of interventions used for the discharge of older people from the emergency department to their home in the community by emergency clinicians.

METHODS

The PRISMA guidelines were followed. The search comprised seven databases including CINAHL Complete, Medline and EMBASE, and additionally unpublished literature sources including trial registries and theses databases. The results were presented for three outcomes: mortality; emergency department representation after the index visit; and physical function. A narrative analysis was performed.

RESULTS

Twenty-five studies met the inclusion criteria; 13 RCTs and 12 quasi-experimental. Risk of bias was moderate to high. There was a trend towards reduced probability of representing to the emergency department within 3 months of the index visit for individualised focussed elder discharge health interventions. Results were equivocal for other outcomes.

CONCLUSIONS

Greater clarity and consensus is needed to determine the most appropriate discharge measures, screening tools, information sources and discharge roles for the emergency setting. Rigorous multicentre trials to improve the evidence on which to base this aspect of emergency care are required.

Disposition Decision Support by Laboratory Based Outcome Prediction

Disposition is one of the main tasks in the emergency department. However, there is a lack of objective and reliable disposition criteria, and diagnosis-based risk prediction is not feasible at early time points. The aim was to derive a risk score (TRIAL) based on routinely collected baseline (TRIage level and Age) and Laboratory data—supporting disposition decisions by risk stratification based on mortality. We prospectively included consecutive patients presenting to the emergency department over 18 weeks. Data sets of routinely collected baseline (triage level and age) and laboratory data were used for multivariable logistic regression to develop the TRIAL risk score predicting mortality. Routine laboratory variables and disposition cut-offs were chosen beforehand by expert consensus. Risk stratification was based on low risk (<1%), intermediate risk (1–10%), and high risk (>10%) of in-hospital mortality. In total, 8687 data sets were analyzed. Variables identified to develop the TRIAL risk score were triage level (Emergency Severity Index), age, lactate dehydrogenase, creatinine, albumin, bilirubin, and leukocyte count. The area under the ROC curve for in-hospital mortality was 0.93. Stratification according to the TRIAL score showed that 67.5% of all patients were in the low-risk category. Mortality was 0.1% in low-risk, 3.5% in intermediate-risk, and 26.2% in high-risk patients. The TRIAL risk score based on routinely available baseline and laboratory data provides prognostic information for disposition decisions. TRIAL could be used to minimize admission in low-risk and to maximize observation in high-risk patients.

Two simple replacements for the Triage Early Warning Score to facilitate the South African Triage Scale in low resource settings

BACKGROUND

The South African Triage Scale (SATS) requires the calculation of the Triage Early Warning Score (TEWS), which takes time and is prone to error.

AIM

to derive and validate triage scores from a clinical database collected in a low-resource hospital in sub-Saharan Africa over four years and compare them with the ability of TEWS to triage patients.

METHODS

A retrospective observational study carried out in Kitovu Hospital, Masaka, Uganda as part of an ongoing quality improvement project. Data collected on 4482 patients was divided into two equal cohorts: one for the derivation of scores by logistic regression and the other for their validation.

RESULTS

Two scores identified the largest number of patients with the lowest in-hospital mortality. A score based on oxygen saturation, mental status and mobility had a c statistic for discrimination of 0.83 (95% CI 0.079-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. Another score based on respiratory rate, mental status and mobility had a c statistic of 0.82 (95% CI 0.078-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. The oxygen saturation-based score of zero points identified 51% of patients in the derivation cohort who had in-hospital mortality rate of 0.5%, and 49% of patients in the validation cohort who had in-hospital mortality of 1.0%. A respiratory rate-based score of zero points identified 45% in the derivation cohort who had in-hospital mortality rate of 0.5%, and 44% of patients in the validation cohort who had in-hospital mortality of 0.8%. Both scores had comparable performance to TEWS.

CONCLUSION

Two easy to calculate scores have comparable performance to TEWS and, therefore, could replace it to facilitate the adoption of SATS in low-resource settings.

Disease Concept-Embedding Based on the Self-Supervised Method for Medical Information Extraction from Electronic Health Records and Disease Retrieval: Algorithm Development and Validation Study

BACKGROUND

The electronic health record (EHR) contains a wealth of medical information. An organized EHR can greatly help doctors treat patients. In some cases, only limited patient information is collected to help doctors make treatment decisions. Because EHRs can serve as a reference for this limited information, doctors' treatment capabilities can be enhanced. Natural language processing and deep learning methods can help organize and translate EHR information into medical knowledge and experience.

OBJECTIVE

In this study, we aimed to create a model to extract concept embeddings from EHRs for disease pattern retrieval and further classification tasks.

METHODS

We collected 1,040,989 emergency department visits from the National Taiwan University Hospital Integrated Medical Database and 305,897 samples from the National Hospital and Ambulatory Medical Care Survey Emergency Department data. After data cleansing and preprocessing, the data sets were divided into training, validation, and test sets. We proposed a Transformer-based model to embed EHRs and used Bidirectional Encoder Representations from Transformers (BERT) to extract features from free text and concatenate features with structural data as input to our proposed model. Then, Deep InfoMax (DIM) and Simple Contrastive Learning of Visual Representations (SimCLR) were used for the unsupervised embedding of the disease concept. The pretrained disease concept-embedding model, named EDisease, was further finetuned to adapt to the critical care outcome prediction task. We evaluated the performance of embedding using t-distributed stochastic neighbor embedding (t-SNE) to perform dimension reduction for visualization. The performance of the finetuned predictive model was evaluated against published models using the area under the receiver operating characteristic (AUROC).

RESULTS

The performance of our model on the outcome prediction had the highest AUROC of 0.876. In the ablation study, the use of a smaller data set or fewer unsupervised methods for pretraining deteriorated the prediction performance. The AUROCs were 0.857, 0.870, and 0.868 for the model without pretraining, the model pretrained by only SimCLR, and the model pretrained by only DIM, respectively. On the smaller finetuning set, the AUROC was 0.815 for the proposed model.

CONCLUSIONS

Through contrastive learning methods, disease concepts can be embedded meaningfully. Moreover, these methods can be used for disease retrieval tasks to enhance clinical practice capabilities. The disease concept model is also suitable as a pretrained model for subsequent prediction tasks.

Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis

BACKGROUND

Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents.

OBJECTIVES

To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents.

RESEARCH DESIGN

We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors.

SUBJECTS

Privately owned, free-standing NHs in the United States (N=13,260).

RESULTS

Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (β=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED.

CONCLUSIONS

Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.

Alerting on mortality among patients discharged from the emergency department: a machine learning model

OBJECTIVES

Physicians continuously make tough decisions when discharging patients. Alerting on poor outcomes may help in this decision. This study evaluates a machine learning model for predicting 30-day mortality in emergency department (ED) discharged patients.

METHODS

We retrospectively analysed visits of adult patients discharged from a single ED (1/2014-12/2018). Data included demographics, evaluation and treatment in the ED, and discharge diagnosis. The data comprised of both structured and free-text fields. A gradient boosting model was trained to predict mortality within 30 days of release from the ED. The model was trained on data from the years 2014-2017 and validated on data from the year 2018. In order to reduce potential end-of-life bias, a subgroup analysis was performed for non-oncological patients.

RESULTS

Overall, 363 635 ED visits of discharged patients were analysed. The 30-day mortality rate was 0.8%. A majority of the mortality cases (65.3%) had a known oncological disease. The model yielded an area under the curve (AUC) of 0.97 (95% CI 0.96 to 0.97) for predicting 30-day mortality. For a sensitivity of 84% (95% CI 0.81 to 0.86), this model had a false positive rate of 1:20. For patients without a known malignancy, the model yielded an AUC of 0.94 (95% CI 0.92 to 0.95).

CONCLUSIONS

Although not frequent, patients may die following ED discharge. Machine learning-based tools may help ED physicians identify patients at risk. An optimised decision for hospitalisation or palliative management may improve patient care and system resource allocation.

Ambulatory Follow-up and Outcomes Among Medicare Beneficiaries After Emergency Department Discharge

IMPORTANCE

Ambulatory follow-up care is frequently recommended after an emergency department (ED) visit. However, the frequency with which follow-up actually occurs and the degree to which follow-up is associated with postdischarge outcomes is unknown.

OBJECTIVES

To examine the frequency and variation in ambulatory follow-up among Medicare beneficiaries discharged from US EDs and the association between ambulatory follow-up and postdischarge outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of 9 470 626 ED visits to 4728 US EDs among Medicare beneficiaries aged 65 and older from 2011 to 2016 who survived the ED visit and were discharged to home used Kaplan-Meier curves and proportional hazards regression. Data analysis was conducted from December 2019 to July 2020.

EXPOSURES

Ambulatory follow-up after discharge from the ED.

MAIN OUTCOMES AND MEASURES

Postdischarge mortality, subsequent ED visit, or inpatient hospitalization within 30 days of an index ED visit.

RESULTS

The study sample consisted of 9 470 626 index outpatient ED visits to 4684 EDs; most visits (5 776 501 [61.0%]) were among women, and the mean (SD) age of patients was 77.3 (8.4) years. In this sample, the cumulative incidence of ambulatory follow-up was 40.5% (3 822 133 patients) at 7 days and 70.8% (6 662 525 patients) at 30 days, after accounting for censoring and for mortality as a competing risk. Characteristics associated with lower rates of ambulatory follow-up included beneficiary Medicaid eligibility (hazard ratio [HR], 0.77; 95% CI, 0.77-0.78; P < .001), Black race (HR, 0.82; 95% CI, 0.81-0.83; P < .001), and treatment at a rural ED (HR, 0.75; 95% CI, 0.73-0.77; P < .001) in the multivariable regression model. Ambulatory follow-up was associated with lower risk of postdischarge mortality (HR, 0.49; 95% CI, 0.49-0.50; P < .001) but higher risk of subsequent inpatient hospitalization (HR, 1.22; 95% CI, 1.21-1.23; P < .001) and ED visits (HR, 1.01; 95% CI, 1.00-1.01; P < .001), adjusting for visit diagnosis, patient demographic characteristics, and chronic conditions.

CONCLUSIONS AND RELEVANCE

In this cohort study of Medicare beneficiaries discharged from the ED, nearly 30% lacked ambulatory follow-up at 30 days, with variation in follow-up rates by patient and hospital characteristics. Having an ambulatory follow-up visit was associated with higher risk of subsequent hospitalization but lower risk of mortality. Ambulatory care access may be an important driver of clinical outcomes after an ED visit.

Trends in Costs of Care for Medicare Beneficiaries Treated in the Emergency Department From 2011 to 2016

IMPORTANCE

There is little evidence regarding how total costs of care associated with an emergency department (ED) visit have changed, despite increasing policy focus on the value of acute care.

OBJECTIVE

To examine trends in total standardized 30-day costs of care associated with an ED visit.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of 14 113 088 ED visits at 4730 EDs from 2011 to 2016 included a 20% national sample of traditional Medicare beneficiaries aged 65 years and older. Data analysis was conducted from August 2018 to April 2020.

EXPOSURES

Time (year) as a continuous variable.

MAIN OUTCOMES AND MEASURES

Trends in disposition from the ED and 30-day total standardized costs for all ED visits as well as the following spending components: index visit cost, physician costs, subsequent ED visit costs, subsequent inpatient costs, subsequent observation costs, non-ED outpatient care, postacute care, and aggregated total spending after the index ED visit.

RESULTS

The analytic sample consisted of 14 113 088 ED visits at 4730 EDs. The mean (SD) beneficiary age was 78.6 (8.6) years, 8 573 652 visits (60.7%) were among women, and 11 908 691 visits (84.7%) were among white patients. The proportion of patients discharged from the ED rose from 1 233 701 of 2 309 563 visits (53.4%) in 2011 to 1 279 701 of 2 268 363 visits (56.4%) in 2016. Total adjusted 30-day standardized costs of care declined from a mean (SE) of $8851 ($35.3) in 2011 to a mean (SE) of $8143 ($35.4) in 2016 (-$126/y; 95% CI, -$130 to -$121; P < .001) for all ED visits. This decrease was primarily associated with a decline in total spending on the index ED visit (-$48/y; 95% CI, -$50 to -$47; P < .001) as well as lower spending on postacute care (-$42/y; 95% CI, -$44 to -$41; P < .001) and subsequent inpatient care (-$34/y; 95% CI, -$36 to -$32; P < .001). There was an increase in spending after the index visit on downstream observation care ($3.6/y; 95% CI, $3.5 to $3.7; P < .001), outpatient ED care ($4.6/y; 95% CI, $4.4 to $4.8; P < .001), and other outpatient care ($15/y; 95% CI, $12 to $18; P < .001).

CONCLUSIONS AND RELEVANCE

In this study, total 30-day standardized costs of ED care for Medicare beneficiaries decreased in recent years. It may be that more intensive ED spending up front is associated with reductions in total costs of an acute episode.

Clinical teams' experiences of crowding in public emergency centres in Cape Town, South Africa

INTRODUCTION

Crowding is a significant challenge for emergency centres (ECs) globally. While South Africa is not alone in reckoning with high patient demand and insufficient resources to treat these patients; staff-to-patient ratios are generally lower than in the Global North. The study of crowding and its consequences for patient care is a key research priority for strengthening the quality and efficacy of emergency care in South Africa. The study set out to understand frontline staff's perspectives on crowding in Cape Town public ECs to learn how they cope in such high- pressure working conditions, determine what they see as the factors contributing to crowding, and obtain their recommendations for reform.

METHODS

This research is a qualitative study from interviews and observations at five ECs in Cape Town, conducted in June and July 2017. In total 43 staff were interviewed individually or in pairs. The interviews included physicians of varying levels of experience (25), and registered or enrolled nurses (18). Data were analysed with the qualitative text-analysis software NVivo.

RESULTS

Both doctors and nurses saw crowding as a consequence of three factors: 1) limited bed space in the EC, 2) insufficient health professionals to care for admitted patients, and 3) the presence of boarders. Systemic or organizational factors as well as human resource scarcity were determined to be the key reasons for crowding.

DISCUSSION

With its high patient acuity and volume and its limited human and material resources, South Africa is an important case study for understanding how emergency care providers manage working in crowded conditions. The solutions to crowding recommended by interviewees were to expand the EC workforce and to add discharge lounges and examination tables.

A simple prognostic score predicts one-year mortality of alert and calm emergency department patients: A prospective two-center observational study

STUDY OBJECTIVE

To derive and validate a prognostic score to predict 1-year mortality using vital signs, mobility and other variables that are readily available at the bedside at no additional cost.

METHODS

Post hoc analysis of two independent prospective observational studies in two emergency departments, one in Denmark and the other in Switzerland.

PARTICIPANTS

Alert and calm emergency department patients.

MEASUREMENTS

The prediction of mortality from presentation to 365 days by vital signs, mobility and other variables that are readily available at the bedside at no additional cost.

RESULTS

One thousand six hundred and eighteen alert and calm patients were in the Danish cohort and 1331 in the Swiss cohort. Logistic regression identified age >68 years, abnormal vital signs, impaired mobility and the decision to admit as significant predictors of 365-day mortality. A simple prognostic score awarded one point to each of these predictors. Less than two of these predictors were present in 45.6% of patients, and only 0.4% of these patients died within a year. If two or more of these predictors were present, 365-day mortality increased exponentially.

CONCLUSION

Age >68 years, the decision for hospital admission, any vital sign abnormality at presentation and impaired mobility at presentation are equally powerful predictors of 1-year mortality in alert and calm emergency department patients. If validated by others these predictors could be used to discharge patients with confidence since nearly half of these patients had less than two predictors and none of them died within 30 days. However, when two or more predictors were present 365-day mortality increased exponentially.

Toppling Oranges: Death, Disability, Decline, and Readmission of Community-Dwelling Elderly Patients After an Emergency Department Visit

BACKGROUND

Every emergency department (ED) faces both a rising tide and a revolving door of elderly patients. Unplanned short-term returns after a recent ED evaluation or hospital admission are sentinel events. Consequences include substantial functional decline, reduced health-related quality of life, and increased risk of dependency or death. Returning families, unaware of the significant likelihood of deterioration after an ED or hospital discharge, often harbor suspicions that something was missed. Literature describing the significant likelihood of functional decline in elderly patients after ED or hospital discharge is presented. Suggestions for incorporating the potential for subsequent deterioration into the evaluation of elderly ED patients and the discussions surrounding disposition decisions are included.

DISCUSSION

In addition to impacting patients and families, posthospitalization decline and short-term readmissions create serious burdens for hospitals and their EDs. Education, vigilance, specialized geriatric EDs, dedicated inpatient units, and ED access to outpatient services for the elderly can aid in the recognition and mitigation of postvisit functional decline and associated returns. Financial incentives for reducing short-term readmissions can translate into novel approaches and referral arrangements.

CONCLUSIONS

Currently, and for the foreseeable future, EDs are integral to predicting, identifying, and preventing functional decline in the elderly. For now, we are all Geriatric EDs.

Trends in Mortality for Medicare Beneficiaries Treated in the Emergency Department From 2009 to 2016

IMPORTANCE

Emergency department (ED) visits are common and increasing. Whether outcomes associated with care in the ED are improving over time is largely unknown to date.

OBJECTIVE

To examine trends in 30-day mortality rates associated with ED care among Medicare beneficiaries aged 65 years or older.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a random 5% sample in 2009 and 2010 and a 20% sample from 2011 to 2016, for a total of 15 416 385 ED visits from 2009 to 2016 among Medicare beneficiaries aged 65 years or older.

EXPOSURES

Time (year) as a continuous variable.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day mortality, overall and stratified by illness severity and hospital characteristics. Secondary outcomes included mortality rates on the day of the ED visit (day 0) as well as at 7 and 14 days. Changes in disposition from the ED (admission, observation, transfer, died in the ED, and discharged) over time were also examined.

RESULTS

The sample included 15 416 385 ED visits (60.8% women and 39.2% men; mean [SD] age, 78.6 [8.5] years) at 4828 acute care hospitals. The percentage of patients discharged from the ED increased from 53.6% in 2009 to 56.7% in 2016. Unadjusted 30-day mortality declined from 5.1% in 2009 to 4.6% in 2016 (-0.068% per year; 95% CI, -0.074% to -0.063% per year; P < .001). After adjusting for hospital random effects, patient demographics, and chronic conditions, the adjusted 30-day mortality trend was -0.198% per year (95% CI, -0.204% to -0.193% per year; P < .001). The magnitude of this trend was greatest for patients with a high severity of illness (-0.662%; 95% CI, -0.681% to -0.644%; P < .001), followed by those with a medium severity of illness (-0.103% per year; 95% CI, -0.108% to -0.097% per year; P < .001) and those with a low severity of illness (-0.009% per year; 95% CI, -0.006% to -0.011% per year; P < .001). Declines in mortality were seen in each category of ED disposition, including visits resulting in admission (-0.356% per year; 95% CI, -0.368% to -0.343% per year; P < .001) as well as those resulting in discharge (-0.059% per year; 95% CI, -0.064% to -0.055% per year; P < .001). The decline was greater for major teaching hospitals (compared with nonteaching hospitals), nonprofit hospitals (compared with for-profit hospitals), and urban hospitals (compared with rural hospitals).

CONCLUSIONS AND RELEVANCE

Among Medicare beneficiaries receiving ED care in the United States, mortality within 30 days of an ED visit appears to have declined in recent years, particularly for patients with the highest severity of illness, even as fewer patients are being admitted from an ED visit. This study's findings suggest that further study is needed to understand the reasons for this decline and why certain types of hospitals are seeing greater improvements in outcomes.

Risk Factors and Causes of Short-Term Mortality after Emergency Department Discharge in Older Patients: Using Nationwide Health Insurance Claims Data

Background

The purpose of this study was to identify the risk factors and causes of short-term mortality after emergency department (ED) discharge in older patients.

Methods

This population-based cohort study used nationwide health insurance claims data in Korea from 2008 to 2014. The causes of death and diagnoses of patients who died within 1 week after discharge from EDs (1-week ED death) were obtained. The risk factors for 1-week ED death were calculated using Cox proportional hazard regression analyses.

Results

The rate of 1-week ED death was 0.5% among 133,251 individuals aged ≥65 years discharged from EDs. In multivariate analysis, the top five ED discharge diagnoses associated with an increased risk of 1-week ED death were hypotension and vascular disease (adjusted hazard ratio [aHR]=5.11; 95% confidence interval [CI], 3.03–8.63), neoplasm (aHR=4.89; 95% CI, 3.77–6.35), coronary artery disease (aHR=3.83; 95% CI, 2.73–5.39), dyspnea (aHR=3.41; 95% CI, 2.48–4.68), and respiratory disease (aHR=2.25; 95% CI, 1.73–2.92). The most common causes of 1-week ED death were neoplasm (14.8%), senility (13.8%), and cerebrovascular disease (11.7%).

Conclusion

Neoplasm, coronary artery disease, and respiratory disease were the discharge diagnoses associated with an increased risk of short-term mortality after ED discharge. Neoplasm was the leading cause of short-term mortality after ED discharge in older patients.

Association of Race/Ethnicity With Emergency Department Destination of Emergency Medical Services Transport

IMPORTANCE

Evidence from national studies indicates systematic differences in hospitals in which racial/ethnic minorities receive care, with most care obtained in a small proportion of hospitals. Little is known about the source of these differences.

OBJECTIVES

To examine the patterns of emergency department (ED) destination of emergency medical services (EMS) transport according to patient race/ethnicity, and to compare the patterns between those transported by EMS and those who did not use EMS.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of US EMS and EDs used Medicare claims data from January 1, 2006, to December 31, 2012. Enrollees aged 66 years or older with continuous fee-for-service Medicare coverage (N = 864 750) were selected for the sample. Zip codes with a sizable count (>10) of Hispanic, non-Hispanic black, and non-Hispanic white enrollees were used for comparison of EMS use across racial/ethnic subgroups. Data on all ED visits, with and without EMS use, were obtained. Data analysis was performed from December 18, 2018, to July 7, 2019.

MAIN OUTCOMES AND MEASURES

The main outcome measure was whether an EMS transport destination was the most frequent ED destination among white patients (reference ED). The secondary outcomes were (1) whether the ED destination was a safety-net hospital and (2) the distance of EMS transport from the ED destination.

RESULTS

The study cohort comprised 864 750 Medicare enrollees from 4175 selected zip codes who had 458 701 ED visits using EMS transport. Of these EMS-transported enrollees, 26.1% (127 555) were younger than 75 years, and most were women (302 430 [66.8%]). Overall, the proportion of white patients transported to the reference ED was 61.3% (95% CI, 61.0% to 61.7%); this rate was lower among black enrollees (difference of -5.3%; 95% CI, -6.0% to -4.6%) and Hispanic enrollees (difference of -2.5%; 95% CI, -3.2% to -1.7%). A similar pattern was found among patients with high-risk acute conditions; the proportion transported to the reference ED was 61.5% (95% CI, 60.7% to 62.2%) among white enrollees, whereas this proportion was lower among black enrollees (difference of -6.7%; 95% CI, -8.3% to -5.0%) and Hispanic enrollees (difference of -2.6%; 95% CI, -4.5% to -0.7%). In major US cities, a larger black-white discordance in ED destination was observed (-9.3%; 95% CI, -10.9% to -7.7%). Black and Hispanic patients were more likely to be transported to a safety-net ED compared with their white counterparts; the proportion transported to a safety-net ED among white enrollees (18.5%; 95% CI, 18.1% to 18.7%) was lower compared with that among black enrollees (difference of 2.7%; 95% CI, 2.2% to 3.2%) and Hispanic enrollees (difference of 1.9%; 95% CI, 1.3% to 2.4%). Concordance rates of non-EMS-transported ED visits were statistically significantly lower than for EMS-transported ED visits; the concordance rate among white enrollees of 52.9% (95% CI, 52.1% to 53.6%) was higher compared with that among black enrollees (difference of -4.8%; 95% CI, -6.4% to -3.3%) and Hispanic enrollees (difference of -3.0%; 95% CI, -4.7% to -1.3%).

CONCLUSIONS AND RELEVANCE

This study found race/ethnicity variation in ED destination for patients using EMS transport, with black and Hispanic patients more likely to be transported to a safety-net hospital ED compared with white patients living in the same zip code.

Is it possible to quickly identify acutely unwell patients who can be safely managed as outpatients? The need for a "Universal Safe to Discharge Score"

If scores or algorithms were developed that quickly identified patients who are bound to have 100% survival, if even only for a few days, more patients could be safely discharged from emergency department, this eliminating the risks of hospitalization for many patients. This hypothesis proposes that it is possible to develop a "Universal Safe to Discharge Score", and suggests how it might be developed and validated.

Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysis

OBJECTIVE

To determine any changes in total hospital revisits within 30 days of discharge after a hospital stay for medical conditions targeted by the Hospital Readmissions Reduction Program (HRRP).

DESIGN

Retrospective cohort study.

SETTING

Hospital stays among Medicare patients for heart failure, acute myocardial infarction, or pneumonia between 1 January 2012 and 1 October 2015.

PARTICIPANTS

Medicare fee-for-service patients aged 65 or over.

MAIN OUTCOMES

Total hospital revisits within 30 days of discharge after hospital stays for medical conditions targeted by the HRRP, and by type of revisit: treat-and-discharge visit to an emergency department, observation stay (not leading to inpatient readmission), and inpatient readmission. Patient subgroups (age, sex, race) were also evaluated for each type of revisit.

RESULTS

Our study cohort included 3 038 740 total index hospital stays from January 2012 to September 2015: 1 357 620 for heart failure, 634 795 for acute myocardial infarction, and 1 046 325 for pneumonia. Counting all revisits after discharge, the total number of hospital revisits per 100 patient discharges for target conditions increased across the study period (monthly increase 0.023 visits per 100 patient discharges (95% confidence interval 0.010 to 0.035)). This change was due to monthly increases in treat-and-discharge visits to an emergency department (0.023 (0.015 to 0.032) and observation stays (0.022 (0.020 to 0.025)), which were only partly offset by declines in readmissions (-0.023 (-0.035 to -0.012)). Increases in observation stay use were more pronounced among non-white patients than white patients. No significant change was seen in mortality within 30 days of discharge for target conditions (-0.0034 (-0.012 to 0.0054)).

CONCLUSIONS

In the United States, total hospital revisits within 30 days of discharge for conditions targeted by the HRRP increased across the study period. This increase was due to a rise in post-discharge emergency department visits and observation stays, which exceeded the decline in readmissions. Although reductions in readmissions have been attributed to improvements in discharge planning and care transitions, our findings suggest that these declines could instead be because hospitals and clinicians have intensified efforts to treat patients who return to a hospital within 30 days of discharge in emergency departments and as observation stays.

Risk of death within 7 days of discharge from emergency departments with different organizational models

OBJECTIVE

The aim of this study is to investigate the association between emergency department (ED) organizational models and the risk of death within 7 days of ED discharge.

PATIENTS AND METHODS

We included Danish ED discharges between 1 January 2011 and 24 December 2014 that led to death within 7 days of discharge. The inclusion criterion was age older than 18 years. The exclusion criterion was further in-hospital admission. First model (Virtual): other departments employ interns who perform ED tasks. They are responsible for ED patient care and prioritize their task order between their own department and the ED. Second model (Hybrid): the ED/other departments perform tasks; interns/consultants are employed by the ED/other departments. The ED/other departments have patient care responsibility. Third model (Independent): the ED performs all tasks; employs interns/consultants; and have patient care responsibility. Sex, age, Charlson Comorbidity Index score, and primary diagnosis were used to describe patient characteristics. We calculated the risk of death within 7 days of discharge using multiple logistic regression analysis.

RESULTS

In 805 out of 201 299 discharges included in the study, the patient died within 7 days. Compared with the Virtual model, the odds ratio for death within 7 days of discharge was 0.72 (95% confidence interval: 0.59-0.92) for the Independent model and 0.75 (95% confidence interval: 0.61-0.92) for the Hybrid+Virtual model. Increased risk was associated with male sex, older age, and a medium or a high Charlson Comorbidity Index score.

CONCLUSION

Compared with discharges from a Virtual model, the risk of death within 7 days of discharge was lower if the ED had an Independent or a Hybrid+Virtual model.