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BOSTON – To admit or not to admit. That is the difficult question faced multiple times a shift by emergency physicians.
Now, a new study published in the BMJ looks at how often Medicare enrollees died in the week after being discharged home from emergency departments, instead of being admitted to the hospital.
To determine that, Brigham and Women’s Hospital researchers and colleagues tracked 16 million visits to U.S. EDs.
“There’s a lot of policy interest in reducing unnecessary admissions from the ED,” explains lead author Ziad Obermeyer, MD, MPhil. “We know that hospitals vary a lot in how often they admit patients to the hospital from the ED, but we don’t know whether this matters for patient outcomes.”
Results from 2007 to 2012 Medicare claims indicate that each year about 10,000 generally healthy patients die in the seven days after discharge from the ED, with heart disease and chronic obstructive pulmonary disease (COPD) the most common causes of death. Narcotic overdose, usually after visits for pain and injuries, also was a leading cause.
The issue didn’t appear to be just a case of physician judgment but also might have been influenced by pressure to lower admission rates, the report suggests. Study authors state that the early deaths were concentrated in hospitals that admitted few patients to the hospital from the ED, pointing out that those are the facilities that are often viewed as lower-cost models by healthcare policy makers.
Mortality rates were considerably lower in large, university-affiliated EDs with higher admission rates and higher costs, according to the report, despite a generally less healthy patient population.
Most likely to die were patients discharged with a diagnosis of confusion, shortness of breath, or generalized weakness, the analysis notes.
“The variation in outcomes that we observed may be linked to gaps in medical knowledge about which patients need more attention from physicians, as well as the geographic and socioeconomic context of emergency care,” suggests Obermeyer, who is also an assistant professor at Harvard Medical School. “Access to resources varies dramatically across hospitals. Obviously not all patients can or should be admitted to the hospital. But we need to focus on admitting the right patients, rather than admitting more or less. I’m optimistic that advanced analytics and better data will help physicians with these kinds of decisions in the future.”