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ED Revisits Much Higher than Expected; But Why?

SAN FRANCISCO – If it seems as if you’re seeing the same patients over and over again in your emergency department, you’re not just having a case of serial déjà vu.

A new study, published recently in Annals of Internal Medicine, points out that one in five patients return to the ED within 30 days of an initial visit, and one in 12 returns after three days.

That’s much more frequent than previously reported, according to study authors from the University of California, San Francisco, and Philip R. Lee Institute for Health Policy Studies in San Francisco.

Noting that little is known about what happens to patients after they are discharged from the ED, researchers reviewed Healthcare Cost and Utilization Project databases for six states from 2006 to 2010 to determine ED revisit rates, variation in revisit rates by diagnosis and state and associated costs.

Across all six states, revisit rates were nearly twice as high as previously reported, according to the study results. Furthermore, only about half of all ED revisits involved a return to the original ED followed by a second discharge home.

With 8.2% of patients revisiting an ED within three days after their original presentation, 32% went to a different hospital. The highest rates occurred with skin infections, 23%. Of the states reviewed, Florida had higher risk-adjusted revisit rates for skin infections, 24.8%, than Nebraska, 10.6%, which had the lowest.

In general, researchers found that total cost of revisits was higher than the total cost of all initial visits. Florida was the only state with complete cost data and total revisit costs for the 19.8% of patients with a revisit within 30 days. The costs there were 118% of total index ED visit costs for all patients, including those with and without a revisit.

It is unknown, according to study authors, whether revisit rates reflect inadequate access to primary care, a planned revisit, the patient's non-adherence to ED recommendations, or poor-quality care at the initial ED visit.

In an accompanying editorial, Kumar Dharmarajan, MD, MBA, and Harlan M. Krumholz, MD, SM, of the Yale School of Medicine in New Haven, CT, write that the findings “highlight an underappreciated problem, the central question of which concerns the potential preventability of revisits.”

Dharmarajan and Krumholz ask, “To what extent do ED revisits represent gaps in quality as opposed to reasonable strategies that prevent admissions at the cost of additional revisits for acute care? How often do revisits represent failures of transitional care, such as poor integration of ED and primary care, suboptimal education of patients and caregivers, or lack of timely follow-up?”