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Abstract
BackgroundCardiac-related complaints are leading drivers of Emergency Department (ED) utilization. Although a large proportion of cardiac patients can be discharged with appropriate outpatient follow-up, inadequate care coordination often leads to high revisit rates or unnecessary admissions. We evaluate the impact of implementing a structured transitional care pathway enrolling low-risk cardiac patients on ED discharges, 30-day revisits and admissions, and institutional revenues.MethodsWe prospectively enrolled eligible patients presenting to a single-center Emergency Department over a 12-month period. Standardized risk measures were used to identify patients suitable for early discharge with cardiology follow-up within 5 days. The primary endpoints were rates of discharge from the ED and 30-day ED revisit and admission rates, with a secondary endpoint including 30-day returns for myocardial infarction. A cost analysis of the program’s impact on institutional revenues was performed.ResultsAmong patients presenting with cardiac-related complaints, rates of discharge from the ED increased from 44.4 to 56.6% (p < 0.0001). Enrollment in the transitional care pathway was associated with a reduced risk of cardiac-related ED revisits (RR 0.22, p < 0.0001), all-cause ED revisits (RR 0.30, p < 0.0001), and admission at second ED visit (RR 0.56, p = 0.0047); among enrolled patients, the 30-day rate of return with a myocardial infarction was 0.35%. No significant reductions were seen in 30-day cardiac-related and all-cause revisits in the 12-months following transitional care pathway implementation; however, there was a significant reduction in admissions at second ED visit from 45.6 to 37.7% (p = 0.0338). An early gender disparity in care delivery was identified in the first 120 days following program implementation that was subsequently eliminated through targeted intervention. There was an estimated decline in institutional revenue of $300 per enrolled patient, driven predominantly by a reduction in admissions.ConclusionsA structured transitional care pathway identifying low-risk cardiac patients who may be safely discharged from the ED can be effective in shifting care delivery from hospital-based to lower cost ambulatory settings without adversely impacting 30-day ED revisit rates or patient outcomes.
Highlights
Cardiac-related complaints are leading drivers of Emergency Department (ED) utilization
Congestive Heart Failure (CHF) is the second leading cause of ED visits resulting in hospitalization among patients aged 65 and older (5.4% of encounters for those over 65), with cardiac arrhythmias ranking fifth among causes of ED visits resulting in hospitalization within this age group (4.3% of encounters for those over 65) [6]
Additional cardiac testing was ordered at the time of a provider encounter as appropriate. Once such testing was completed and the results reviewed with the patient, further cardiology follow-up was scheduled if needed; otherwise, the patient was discharged from HEART TRACKS, at which time their primary care provider (PCP) was notified by correspondence of the patient’s ED visit
Summary
A large proportion of cardiac patients can be discharged with appropriate outpatient follow-up, inadequate care coordination often leads to high revisit rates or unnecessary admissions. Inadequate care coordination of patients that are discharged from the ED lessens much of the benefit to both patients and the healthcare system that can be derived from these risk stratification and early discharge strategies. This failure to ensure timely follow-up is a source of potentially avoidable ED revisits and their associated healthcare costs, including preventable admissions [9]. There is a growing literature base demonstrating the benefits of improved care coordination among patients discharged from the hospital following an admission [11,12,13,14], there remains a paucity of data examining the impact of improved care coordination among patients being discharged directly from the ED
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