10,000 Medicare patients die in the seven days after discharge from the ED
Around 10,000 patients in generally good health die in the week after being discharged from the emergency department, according to researchers at the Brigham and Women’s Hospital. Tracking approximately 16m visits to the emergency department, the research team found that heart disease and COPD were the most frequent causes of death, but there was also a high rate of narcotic overdoses after visits for pain and injury. The deaths occurred more often in hospitals that admitted less patients from the ED into the hospital, a strategy that has been praised by policy makers for being lower cost. Higher cost, higher admission hospitals saw less deaths, despite the fact that their patients were generally more unwell when they arrived at the ED. Those patients suffering from confusion, generalized weakness or shortness of breath on discharge were more likely to die, but those with chest pain were at a lower risk of death. Any patients over the age of 90 years old, or with known serious illness, or in receipt of palliative care were excluded from the research. The researchers believe the variation in patient survival rates are possibly due to medical knowledge gaps in terms of patients requiring extended attention, as well as the geographic and socioeconomic environment. The team recommended using analytics and data to help physicians determine which patients should be admitted for further care.
Nearly one in five Americans will visit an emergency department (ED) each year, meaning that physicians make the decision to admit or discharge a patient from the ED hundreds of thousands of times daily, but little is known about how patients fare after they are sent home from the ED. Researchers at Brigham and Women's Hospital measured how often generally healthy Medicare enrollees died in the seven days after being discharged home, by tracking over 16 million visits to U.S. EDs.

The findings are published in the February 1 edition of the British Medical Journal.

"There's a lot of policy interest in reducing unnecessary admissions from the ED," said Ziad Obermeyer, MD, MPhil, a staff physician in the Department of Emergency Medicine at BWH. "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."

Researchers found that, each year, about 10,000 generally healthy patients die in the seven days after discharge from the ED. Heart disease and COPD were the most common causes of death, but narcotic overdose was also a leading cause, largely after visits for pain and injuries.

These early deaths were concentrated in hospitals that admitted few patients to the hospital from the ED, hospitals that are often viewed as models by policy makers because of their low costs. By contrast, deaths were far less frequent in large, university-affiliated EDs with higher admission rates and higher costs, even though the population served by these EDs was generally less healthy when they walked in the front door of the ED.

Patients discharged with a diagnosis of confusion, shortness of breath, or generalized weakness were more likely to die, while those with chest pain were at significantly lower risk. Researchers analyzed data from Medicare claims that covered ED visits from 2007-2012 to identify patients who died in the week after discharge. Patients with known serious illnesses or diagnoses of life threatening conditions in the ED and those over 90 years old, or receiving palliative care were excluded.

"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. Access to resources varies dramatically across hospitals," said Obermeyer, who is also an assistant professor at Harvard Medical School. "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."

More information: Ziad Obermeyer et al. Early death after discharge from emergency departments: analysis of national US insurance claims data, BMJ (2017). DOI: 10.1136/bmj.j239 Journal information: British Medical Journal (BMJ)