Study questions validity of quality measure of emergency care

Hospital admissions associated with return visits to the emergency department (ED) may not adequately capture deficits in the quality of care delivered during an ED visit, according to a study in JAMA.

All-cause hospital readmissions are considered to capture deficits in transitions of care from the hospital setting and are now a reportable measure of hospital quality tied to financial penalties for poor-performing hospitals. Similar to the rationale for monitoring performance using hospital readmissions, unscheduled return visits after ED discharge may also reflect inadequate ED discharge practices or follow-up procedures. Short-term unscheduled return visits to the ED are increasingly monitored as an administrative performance measure and have been considered for wider adoption as a measure of the quality of emergency care, particularly if the patient requires hospitalization during the return ED visit. However, the ramifications of using return visits to the ED as a measure of quality are uncertain.

Amber K. Sabbatini, M.D., M.P.H., of the University of Washington, Seattle, and colleagues examined in-hospital clinical outcomes and resource use among patients who had a return visit to the ED and subsequent hospital admission compared with patients who were hospitalized and did not experience a return visit to the ED. The authors analyzed adult ED visits to acute care hospitals in Florida and New York in 2013 using data from the Healthcare Cost and Utilization Project. Patients with index ED visits were identified and followed up for return visits to the ED within 7, 14, and 30 days.

The study included 9,036,483 index ED visits to 424 hospitals. The authors found that patients who experienced an ED return visit that resulted in admission shortly after an earlier ED discharge had significantly lower rates of in-hospital mortality, intensive care unit (ICU) admission, and costs, but somewhat longer lengths of hospital stay compared with admissions among patients without a return visit to the ED. In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher mortality and ICU admission rates during the repeat hospitalization along with longer lengths of stay and higher costs. Results were consistent for patients returning to the ED within 7, 14, or 30 days of their initial ED visit.

"These findings suggest that ED return admissions may not adequately capture deficits in the quality of care delivered during an ED visit based on information from administrative data sets," the authors write.

"How rates of return visits to the ED are interpreted - as reflecting medical error or as a failure of an appropriate trial of outpatient management - has important policy implications for a value-driven health care system. Recent changes in health care financing, such as payer scrutiny over short-stay hospitalizations, physician profiling with pay-for-performance incentives or penalties, and expansion of risk-sharing agreements have placed increased pressure on hospitals and physicians to reduce unnecessary admissions."

Editorial: Ensuring the Quality of Quality Metrics for Emergency Care

These findings provide a definitive argument that the overall ED revisit rate should not be used as a quality metric, writes James G. Adams, M.D., of Northwestern University and Northwestern Memorial HealthCare, Chicago, in an accompanying editorial. "Although potentially sensitive, this measure is recognized as too nonspecific. To identify misdiagnoses and inadequate treatment, a more precise approach is warranted."

"The journey toward better, meaningful quality measures continues with the realization that there is no easily accessible measure for overall ED diagnostic and therapeutic quality. The fact that this key question is answered serves as a good reminder that much detailed, difficult, and diligent work lies ahead."