Abstract
BackgroundGiven system-level focus on avoidance of unnecessary hospitalizations, better understanding admission decision-making is of utility. Our study sought to identify factors associated with hospital admission versus discharge from the Emergency Department (ED) for a population of patients who were assessed as having low medical acuity at time of decision.MethodsUsing an institutional database, we identified ED admission requests received from March 1, 2018 to Feb 28, 2019 that were assessed by a physician at the time of request as potentially inappropriate based on lack of medical acuity. Focused chart review was performed to extract data related to patient demographics, socioeconomic information, measures of illness, and system-level factors such as previous healthcare utilization and day/time of presentation. A binary logistic regression model was constructed to correlate patient and system factors with disposition outcome of admission to the hospital versus discharge from the ED. Physician-reported contributors to admission decision-making and chief complaint/reason for admission were summarized.ResultsA total of 349 (77.2%) of 452 calls resulted in admission to the hospital and 103 (22.8%) resulted in discharge from the ED. Predictors of admission included age over 65 (OR 3.5 [95%CI 1.1–11.6], p = 0.039), homelessness (OR 3.3 [95% CI 1.7–6.4], p=0.001), and night/weekend presentation (OR 2.0 [95%CI 1.1–3.5], p = 0.020). The most common contributing factors to the decision to admit reported by the responding physician included: lack of outpatient social support (35.8% of admissions), homelessness (33.0% of admissions), and substance use disorder (23.5% of admissions).ConclusionsPhysician medical decision-making regarding the need for hospitalization incorporates consideration of individual patient characteristics, social setting, and system-level barriers. Interventions aimed at reducing unnecessary hospitalizations, especially those involving patients with low medical acuity, should focus on underlying unmet needs and involve a broad set of perspectives.
Highlights
Given system-level focus on avoidance of unnecessary hospitalizations, better understanding admission decision-making is of utility
Socioeconomic factors, and measures of illness Patients in this study were middle-aged, predominantly male (286/452; 63.3%), English-speaking (371/452; 82.1%), and covered by public insurance (388/452; 85.8%)
While recognizing that patient care requires a collaborative and interprofessional approach, we focus on the triage physician decisions since both the decision to admit and admission appropriateness assessment are determined by the same individual
Summary
Given system-level focus on avoidance of unnecessary hospitalizations, better understanding admission decision-making is of utility. The number of preventable ( called avoidable) admissions is widely used as a health care system quality indicator across the globe [6] and is an active target for cost containment strategies [7] Critiques of this approach point to a lack of validation studies, limited understanding of complex underlying contributors, and questions regarding whether these hospitalizations are truly preventable [8,9,10,11,12]. Given the complexity surrounding assessment of preventability, a potentially informative related concept is identification of “inappropriate” admissions for which hospitalization is not thought to be necessary or of benefit to the patient This is often determined using medical records via utilization review [15] or by application of a standardized tool such as the Appropriateness Evaluation Protocol (AEP) [16]. Deeper analysis is warranted and further work “... to understand the process through which decisions about hospitalization are made in the ED” [27] has been identified as an important area of focus
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