February 02, 2017
A recent study in The BMJ found that deaths among Medicare patients discharged from emergency departments (EDs) were higher in rural hospitals with lower inpatient admission rates (BMJ. 2017;356:j239).
Under the Affordable Care Act, hospitals are under pressure to reduce care measures such as hospital admissions and readmission, in an effort to reduce spending and improve accountability for care quality. However, findings by Ziad Obermeyer, MD, of the department of emergency medicine at Harvard Medical School, and colleagues, may question the value and accuracy of those measures.
“There’s no doubt there’s a lot of unnecessary hospital admissions, but this study suggests there’s also avoidable harm from sending people home that shouldn’t go home,” Dr Obermeyer told STAT, according to a recent report.
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The study suggests that the hospitals with the lowest inpatient admission rates, which are often rural hospitals, are also the ones that had higher rates of unexpected deaths among patients. It is estimated that approximately 20% of the US population each year visit an ED. As a result, providers in the United States are forced to determine to admit or discharge patients from the ED hundreds of thousands times a day, according to the study. Furthermore, it is estimated that approximately 10,000 Medicare patients who do not have life threatening illnesses die each year within 7 days of being released from the ED.
In order to determine the death rates among discharged patients, the researchers examined data on care provided to an estimated 16 million Medicare beneficiaries between 2007 and 2012. The researchers focused specifically on healthy patients, and excluded records for patients with life-threatening illnesses or who were in nursing homes.
According to the study findings, about 0.12% of the examined discharged patients died within 7 days, which totaled roughly 10,000 unexpected deaths per year. Hospitals with lower admission rates had a death rate that was 3.4 times higher when compared to hospitals with higher admission rates. Additionally, the researchers noted that hospitals with lower admission rates discharged 85% of patients while hospitals with higher admission rates discharged only 44%.
“It doesn’t seem that the deaths are due to random chance,” Dr Obermeyer told STAT. “There is something different going on in those low-admission-rate hospitals.”
The researchers suggested that the illness severity is unlikely to impact the findings. Heart disease (13.6%), myocardial infarction (10.3%), chronic obstructive pulmonary disease (9.6%), and narcotic overdose following visits for musculoskeletal problems (2.3%) were all found to be common causes of death among discharged patients.
“Many Medicare beneficiaries die shortly after discharge from emergency departments, despite no obvious life limiting illnesses recorded in their claims,” Dr Obermeyer and colleagues concluded. “Hospitals with low admission rates and low patient volumes, and patients with high risk diagnoses at discharge, could represent targets for clinical research and quality improvement efforts.”
—Julie Gould (Mazurkiewicz)