When readmissions went down, return visits to ED and observation went up

Researchers compared more than 200,000 hospitalizations for acute myocardial infarction, heart failure, or pneumonia in 2009 and 2010 to matched hospitalizations in 2013 and 2014.

Readmissions declined for some of the conditions targeted by Medicare, but at the same time, observation and ED visits by recently hospitalized patients increased, leading to no overall improvement in returns to the hospital, a recent study found.

Researchers used Healthcare Cost and Utilization Project data to compare 210,007 hospitalizations for acute myocardial infarction, heart failure, or pneumonia in 2009 and 2010 to 212,833 matched hospitalizations in 2013 and 2014. The data included patients with private insurance, Medicare, Medicaid, or no insurance, treated at any of 201 hospitals in Georgia, Nebraska, South Carolina, and Tennessee. Results were published online by the Journal of Hospital Medicine on Nov. 22.

The overall rate of return to the hospital (for inpatient admission, observation, or discharge from the ED) remained stable in patients with private insurance (15.1% in 2009 and 2010 vs. 15.3% in 2013 and 2014), declined slightly in those with Medicare (25.3% vs. 25.0%), and rose in those with Medicaid (31.0% vs. 32.1%) or no insurance (18.8% vs. 20.1%). Observation and ED visits increased in all groups, and inpatient readmissions decreased only for patients with Medicare (18.3% vs. 16.9%) or private insurance (8.9% vs. 8.2%), remaining stable in Medicaid and uninsured patients. The study authors concluded that “total returns to the hospital are stable or rising, likely because of growth in observation and ED visits.”

They offered three possible reasons for the shift from readmissions to observation and ED care: 1) intentional use of observation status to avoid readmissions for targeted conditions, 2) general shifts in practice patterns to care for more patients under observation or in the ED instead of as inpatients, 3) patients returning for more low-acuity problems due to discharge education initiatives (i.e., patients were advised to seek medical attention for worrisome symptoms). The authors thought the overall increases in hospital returns among Medicaid and uninsured patients might also be explained by another factor: lack of access to ambulatory care.

Regardless of the cause of the findings, measuring readmission rates without counting ED visits and observation care underestimates hospital returns, the authors wrote. “Irrespective of payer, hospitalists' efforts to improve the quality and value of care should include observation and ED visits as well as inpatient readmissions.”