30-day Emergency Department Revisits Research Articles

Comparative Analysis of Short-Term Outcomes of Patients With Heart Failure With a Mid-Range Ejection Fraction After Acute Decompensation

To determine short-term outcomes after an episode of acute heart failure in patients with mid-range ejection fraction (40%-49%; HFmrEF) compared with patients with reduced (<40%) and preserved (>49%) ejection fractions (HFrEF and HFpEF, respectively) and according to their final destination after emergency department (ED) care. This is an exploratory, secondary analysis of the Epidemiology of Acute Heart Failure in the Emergency departments Registry, which includes consecutive acute heart failure patients diagnosed in 41 Spanish EDs. Patients with echocardiography data were included and divided into HFrEF, HFmrEF, and HFpEF. The primary outcome was 30-day all-cause mortality, and secondary outcomes were in-hospital all-cause mortality, hospital length of stay >10 days, and 30-day postdischarge ED revisit due to AHF and combined end point (ED revisit and/or death). We included 6,856 patients (age 79 [10]; 52.1% women): 21.6% had HFrEF, 14.3% HFmrEF, and 64.1% HFpEF. The main destinations for the 982 HFmrEF patients after ED management were internal medicine (293, 29.8%), cardiology (194, 19.9%) and not hospitalized (241, 24.5%), whereas the remaining 254 patients were admitted to other departments, including geriatric wards, short-stay units and intensive care units. Outcomes for HFmrEF did not differ compared with either HFrEF or HFpEF. Compared with HFmrEF admitted to cardiology, internal medicine admission or direct ED discharge increased the 30-day postdischarge ED revisit (hazard ratio [HR] 1.713, 95% confidence interval [CI] 1.042 to 2.816; and HR 1.683, 95% CI 1.046 to 2.708, respectively) and the 30-day postdischarge combined end point (HR 1.732, 95% CI 1.070 to 2.803; and HR 1.727, 95% CI 1.083 to 2.756, respectively). In conclusion, patients in the newly created HFmrEF category suffering from an acute decompensation have similar short-term outcomes as those in the classical HFrEF and HFpEF categories; nonetheless, HFmrEF patients handled in cardiology wards during decompensation obtain better outcomes, and reasons for these differences have to be unmasked and corrected.

Implementation and impact analysis of a transitional care pathway for patients presenting to the emergency department with cardiac-related complaints

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.

Gaining knowledge of Ontario’s community mental health and addictions system: linking community-based health services data with administrative health data in Toronto, Ontario, Canada

IntroductionIn most developed countries, a significant amount of mental health and addictions care occurs in community settings. Data reflecting populations served by community-based mental health and addictions providers and the types of services provided are not available, resulting in an incomplete reflection of the entire mental health and addictions system within existing administrative data.&#x0D; Objectives and ApproachThe Community Business Intelligence (CBI) initiative is a data collection project that captures information on adults receiving community-based mental health, addictions, and support services in Toronto Central Local Health Integration Network (LHIN), located in Ontario, Canada. Leveraging administrative health data and data linkage capacity at the Institute for Clinical Evaluative Sciences (ICES), along with engagement of external stakeholders knowledgeable of CBI and the community health sector, we linked the 2015/16 CBI dataset to administrative health data. Demographic characteristics, health-service utilization, primary care attachment, and 30-day emergency department (ED) revisits were calculated for individuals accessing community health services.&#x0D; ResultsThere was an 80.8% linkage rate, of which 36.9% linked deterministically via health card number, while 43.9% linked probabilistically. After study exclusions, 37,688 individuals in the CBI dataset used community health services between April 2015 and March 2016. Compared to Toronto Central LHIN, a greater proportion in the CBI dataset were female, older than 65 years of age, and living in a low income neighbourhood. Furthermore, 95.5%of individuals had at least one outpatient physician visit, 51.3%had at least one ED visit, and 21.7%had at least one hospitalization in the past year. Few individuals in the CBI dataset were without primary care attachment (4.5%); however, a larger proportion had a 30-day ED revisit, particularly those receiving community addictions services (19%).&#x0D; Conclusion/ImplicationsThe availability of community health services data in the CBI dataset and its successful linkage to the administrative health data held at ICES identified health service intersections and outcomes that were previously unknown. This linkage project demonstrates a successful framework for sector-wide performance measurement to address a critical infrastructure gap.

Perceived Access to Outpatient Care and Hospital Reutilization Following Acute Respiratory Illnesses

ObjectiveEfforts to decrease hospital revisits often focus on improving access to outpatient follow-up. Our objective was to assess the relationship between perceived access to timely office-based care and subsequent 30-day revisits following hospital discharge for 4 common respiratory illnesses. MethodsThis was a prospective cohort study of children 2 weeks to 16years admitted to 5 US children's hospitals for asthma, bronchiolitis, croup, or pneumonia between July 2014 and June 2016. Hospital and emergency department (ED) (in the case of croup) admission surveys administered to caregivers included the Consumer Assessments of Healthcare Providers and Systems Timely Access to Care. Access composite scores (range 0–100, with greater scores indicating better access) were linked with 30-day ED revisits and inpatient readmissions from the Pediatric Health Information System. The relationship between access to timely care and repeat utilization was assessed using multivariable logistic regression adjusting for demographics, hospitalization, and home/outpatient factors. ResultsOf the 2438 children enrolled, 2179 (89%) reported an office visit in the previous 6 months. Average access composite score was 52.0 (standard deviation, 36.3). In adjusted analyses, greater access scores were associated with greater odds of 30-day ED revisits (odds ratio [OR] = 1.07; 95% confidence interval [CI], 1.02–1.13)—particularly for croup (OR = 1.17; 95% CI, 1.02–1.36)—but not inpatient readmissions (OR = 1.02; 95% CI, 0.96–1.09). ConclusionsPerceived access to timely office-based care was associated with significantly greater odds of subsequent ED revisit. Focusing solely on enhancing timely access to care following discharge for common respiratory illnesses may be insufficient to prevent repeat utilization.

Abstract 191: Trends in Hospitalization and Readmission of Patients With Syncope: An Analysis Using State Inpatient and Emergency Department Databases

Background: Syncope accounts for 1% of US emergency department (ED) visits. Because the etiology of syncope is often benign, diagnostic testing for syncope can be low yield and routine hospitalization has not been shown to improve outcomes. Thus, professional society guidelines from cardiology and emergency medicine have advocated shifting priorities in the decision to hospitalize patients from a focus on determining the etiology of syncope to stratifying the need for hospitalization by patients’ cardiac risk. Changes in utilization and clinical outcomes as a result of this paradigm shifts are not known. Thus, our objective was to characterize longitudinal changes in hospitalization and readmission rates of patients presenting to the ED with syncope. Methods: Using linked State Inpatient and Emergency Department Databases from the Agency for Healthcare Research and Quality, we conducted a retrospective study of all ED visits in 12 geographically diverse states in 2009 and 2013. First, we calculated annual incidence rates of syncope ED visits and subsequent hospitalizations. We then calculated 30-day ED revisit and hospital readmission rates for the subset of 3 states with readmission identifiers. Differences between years were estimated using mixed effect regression modeling adjusted for patient clinical and demographic characteristics and hospital random effects. Results: We identified 471,379 ED visits for syncope in 2009 and 535,521 ED visits in 2013. The annual incidence of syncope ED visits increased by 11.4% from 697 to 777 visits per 100,000 persons. Rates of subsequent hospitalization decreased from 41.2% in 2009 to 29.0% in 2013 (Adjusted Odds Ratio [AOR] 0.50; 95% CI [0.47-0.52]). Though age was the strongest predictor of hospitalization, hospitalization rates decreased across all age groups, (7.2% to 4.7% for patients ages 18-25, p&lt;.0001, and 66.6% to 52.3% for patients age ≥85, p&lt;.0001). The 30-day ED revisit rate following an index syncope ED visit decreased for patients discharged from the ED during the index visit (14.2% in 2009 to 13.7% in 2013; AOR 0.96 [95% CI 0.93-0.98]) and did not significantly change for patients admitted during the index visit (16.0% in 2009 to 16.5% in 2013; AOR 1.01 [95% CI 0.98-1.05]). The 30-day readmission rate decreased for patients discharged from the ED during the index visit (4.3% in 2009 to 3.9% in 2013, p&lt;.0001) and did not significantly change for patients admitted during the index visit (9.7% in 2009 to 9.5% in 2013, p=.19). Conclusions: Although the incidence of ED visits for syncope increased from 2009 to 2013, hospitalization rates for declined by 25% without an adverse effect on ED revisits or hospital readmissions.

Heart failure education in the emergency department markedly reduces readmissions in un- and under-insured patients

BackgroundHeart failure (HF) readmissions are a longstanding national healthcare issue for both hospitals and patients. Our purpose was to evaluate the efficacy of a structured, educational intervention targeted towards un- and under-insured emergency department (ED) HF patients. MethodsHF patients presenting to the ED for care were enrolled between July and December 2015 as part of an open label, interventional study, using a parallel observational control group. Eligible patients provided informed consent, had an established HF diagnosis, and were hemodynamically stable. Intervention patients received a standardized educational intervention in the ED waiting room before seeing the emergency physician, and a 30-day telephone follow-up. Primary and secondary endpoints were 30- and 90-day ED and hospital readmission rates, as well as days alive and out of hospital (DAOH) respectively. ResultsOf the 94 patients enrolled, median age was 58.4 years; 40.4% were female, and 54.3% were African American. Intervention patients (n = 45) experienced a 47.8% and 45.3% decrease in ED revisits (P = 0.02 &P < 0.001), and 60.0% and 47.4% decrease in hospital readmissions (P = 0.049 &P = 0.007) in the 30 and 90 days pre- versus post-intervention respectively. Control patients (n = 49) had no change in hospital readmissions or 30-day ED revisits, but experienced a 36.6% increase in 90-day ED revisits (P = 0.03). Intervention patients also saw a 59.2% improvement in DAOH versus control patients (P = 0.03). ConclusionAn ED educational intervention markedly decreases ED and hospital readmissions in un- and under-insured HF patients.

Predictors and Outcomes of Revisits in Older Adults Discharged from the Emergency Department.

To study predictors of emergency department (ED) revisits and the association between ED revisits and 90-day functional decline or mortality. Multicenter cohort study. One academic and two regional Dutch hospitals. Older adults discharged from the ED (N=1,093). At baseline, data on demographic characteristics, illness severity, and geriatric parameters (cognition, functional capacity) were collected. All participants were prospectively followed for an unplanned revisit within 30 days and for functional decline and mortality 90 days after the initial visit. The median age was 79 (interquartile range 74-84), and 114 participants (10.4%) had an ED revisit within 30 days of discharge. Age (hazard ratio (HR)=0.96, 95% confidence interval (CI)=0.92-0.99), male sex (HR=1.61, 95% CI=1.05-2.45), polypharmacy (HR=2.06, 95% CI=1.34-3.16), and cognitive impairment (HR=1.71, 95% CI=1.02-2.88) were independent predictors of a 30-day ED revisit. The area under the receiver operating characteristic curve to predict an ED revisit was 0.65 (95% CI=0.60-0.70). In a propensity score-matched analysis, individuals with an ED revisit were at higher risk (odds ratio=1.99 95% CI=1.06-3.71) of functional decline or mortality. Age, male sex, polypharmacy, and cognitive impairment were independent predictors of a 30-day ED revisit, but no useful clinical prediction model could be developed. However, an early ED revisit is a strong new predictor of adverse outcomes in older adults.

Implementation of a Process for Initiating Naltrexone in Patients Hospitalized for Alcohol Detoxification or Withdrawal.

Naltrexone trials have demonstrated improved outcomes for patients with alcohol use disorders. Hospital initiation of naltrexone has had limited study. To describe the implementation and impact of a process for counseling hospitalized patients with alcohol withdrawal about naltrexone. A pre-post study analysis. A tertiary academic center. Patients hospitalized for alcohol withdrawal. (1) Provider education about the efficacy and contraindications of naltrexone and (2) algorithms for evaluating patients for naltrexone. The percentages of patients counseled about and prescribed naltrexone before discharge and the percentages of pre- and postintervention patients with 30-day emergency department (ED) revisits and rehospitalizations. We identified 128 patient encounters before and 114 after implementation. The percentage of patients counseled about naltrexone rose from 1.6% preimplementation to 63.2% postimplementation (P<.001); the percentage of patients prescribed naltrexone rose from 1.6% to 28.1% (P<.001). Comparing preintervention versus postintervention groups, there were no unadjusted differences in 30-day ED revisits (25.8% vs 19.3%; P=.23) or rehospitalizations (10.2% vs 11.4%; P=.75). When adjusted for demographics and comorbidities, postintervention patients had lower odds of 30-day ED revisits (odds ratio [OR]=0.47; 95% confidence interval [CI], 0.24-0.94) but no significant difference in rehospitalizations (OR=0.76; 95% CI, 0.30-1.92). In subgroup analysis, postintervention patients counseled versus those not counseled about naltrexone were less likely to have 30-day ED revisits (9.7% vs 35.7%; P=.001) and rehospitalizations (2.8% vs 26.2%; P<.001). The implementation of a process for counseling patients hospitalized for alcohol withdrawal about using naltrexone for the maintenance of sobriety was associated with lower 30-day ED revisits but no statistically significant difference in rehospitalizations.

Variation in Care and Clinical Outcomes in Children Hospitalized With Orbital Cellulitis.

To describe variation in the care of children hospitalized with orbital cellulitis and to determine associations with length of stay (LOS), emergency department (ED) revisits, and hospital readmissions. By using the Pediatric Health Information System, we performed a multicenter, retrospective study of children aged 2 months to 18 years with a primary International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code for orbital cellulitis from 2007 to 2014. We assessed hospital-level variation in the use of diagnostic tests, corticosteroids, and antibiotics individually and in aggregate for association with outcomes (LOS, ED revisits, readmissions) after risk-adjusting for important clinical and demographic factors. A total of 1828 children met inclusion criteria. Complete blood cell counts (median [interquartile range]: 81.8% [66.7-89.6]), C-reactive protein levels (57.1% [22.2-84.0]), blood cultures (57.9% [48.9-63.6]), and computed tomography imaging (74.7% [66.7-81.0]) were the most frequently performed diagnostic tests, with significant variation observed across hospitals (all P < .001). Corticosteroids were used in 29.2% of children (interquartile range: 18.4-37.5). There was significant variation in antibiotic exposure across hospitals (P < .001). Increased total diagnostic test usage was associated with increased LOS (P = .044), but not with 30-day ED revisits (P = .176) or readmissions (P = .403). Children hospitalized with orbital cellulitis experience wide variation in clinical management. Increased hospital-level usage is associated with increased LOS. Our findings highlight a critical need to identify treatment strategies that optimize resource use and outcomes for children hospitalized with orbital cellulitis.

The Effect of Utilization Review on Emergency Department Operations

Increasingly, hospitals are using utilization review software to reduce hospital admissions in an effort to contain costs. Such practices have the potential to increase the number of unsafe discharges, particularly in public safety-net hospitals. Utilization review software tools are not well studied with regard to their effect on emergency department (ED) operations. We study the effect of prospectively used admission decision support on ED operations. In 2012, Los Angeles County+ University of Southern California Medical Center implemented prospective use of computerized admission criteria. After implementation, only ED patients meeting primary review (diagnosis-based criteria) or secondary review (medical necessity as determined by an on-site emergency physician) were assigned inpatient beds. Data were extracted from electronic medical records from September 2011 through December 2013. Outcomes included operational metrics, 30-day ED revisits, and 30-day admission rates. Excluding a 6-month implementation period, monthly summary metrics were compared pre- and postimplementation with nonparametric and negative binomial regression methods. All adult ED visits, excluding incarcerated and purely behavioral health visits, were analyzed. The primary outcomes were disposition rates. Secondary outcomes were 30-day ED revisits, 30-day admission rate among return visitors to the ED, and estimated cost. Analysis of 245,662 ED encounters was performed. The inpatient admission rate decreased from 14.2% to 12.8%. Increases in discharge rate (82.4% to 83.4%) and ED observation unit utilization (2.5% to 3.4%) were found. Thirty-day revisits increased (20.4% to 24.4%), although the 30-day admission rate decreased (3.2% to 2.8%). Estimated cost savings totaled $193.17 per ED visit. The prospective application of utilization review software in the ED led to a decrease in the admission rate. This was tempered by a concomitant increase in ED observation unit utilization and 30-day ED revisits. Cost savings suggest that resources should be redirected to the more highly affected ED and ED observation unit, although more work is needed to confirm the generalizability of these findings.

The effect of a short-stay unit on hospital admission and length of stay in acute heart failure: REDUCE-AHF study

To determine whether the presence of a short-stay unit(SSU) in a hospital influences the percentage of admissions, length of hospital stay(LOS) and outcomes in emergency department(ED) patients with acute heart failure(AHF). Retrospective analysis of AHF patients presenting to one of 34 Spanish ED included in EAHFE registry. Baseline and ED data of patients were collected. Patients were classified into two groups in function of being attended at hospitals with or without a SSU. Main outcome variables were the percentage of admissions from ED, and LOS for admitted patients. Secondary variables were all-cause death and ED revisits for worsening heart failure within 30days following discharge. Of 9078 patients presenting to the ED (SSU 5191; no SSU 3887), 6796 (74.8%) were admitted. Compared to hospitals without a SSU, the admission rate in hospitals with a SSU was 8.9% higher (95%CI 6.5%-11.4%), but 30-day ED revisit and mortality rates were lower among patients discharged directly from the ED (-10.3%, 95%CI -16,9% to -3.7%; and -10.0%, 95%CI -16.6 to -3.4%, respectively). For admitted patients, the overall LOS was 9.3±9.5days, being 2.2days shorter (95%CI -2.7 to -1.7) in hospitals with a SSU, with no significant differences in in-hospital, 30-day mortality or 30-day ED revisit rates. The data suggest that SSU may improve the safety of emergency care of patients with AHF, but at the cost of a higher rate of hospital admissions, and it may also reduce the LOS for admitted patients without affecting post discharge safety.

Opioid prescription practices at discharge and 30-day returns in children with sickle cell disease and pain.

Acute pain episodes in children with sickle cell disease (SCD) represent a leading cause of readmissions. We examined prescription practices at the time of discharge in children with SCD presenting with acute pain to determine their impact on 30-day emergency department (ED) revisits and readmissions. In this single-institution, 5-year retrospective study, we reviewed 290 encounters of patients with SCD aged 7-21 years hospitalized or discharged from the ED with acute pain. We reviewed demographic, treatment and discharge data, and 30-day returns, defined as ED revisits and readmissions within 30 days of discharge. Bivariate and multivariable analyses were performed to evaluate the association between discharge prescription practices and 30-day returns. Compared to hospitalizations, treat-and-release ED visits for acute pain were associated with a higher incidence of 30-day returns (OR = 2.7 [95% CI: 1.5-4.8],P< 0.01). We found no association between prescribed opioid frequency (scheduled vs. as-needed) and 30-day returns (OR = 1.12 [95% CI: 0.62-2.02], P = 0.70). By multivariable logistic regression, the prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) only, without opioids, after treat-and-release ED visits was independently associated with a higher frequency of 30-day ED revisits (OR = 6.9 [95% CI: 1.3-37.3], P = 0.03) but not readmissions. Variability exists in opioid prescription practices after discharge in children with SCD and pain episodes. Prescription of NSAIDs only, without opioids, was an independent predictor of higher 30-day ED revisits. Formalized studies to better understand factors that influence returns, including outpatient opioid management, are warranted in this population.

Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions.

IntroductionPatients with mental health conditions frequently use emergency medical services. Many suffer from substance use and homelessness. If they use the emergency department (ED) as their primary source of care, potentially preventable frequent ED revisits and hospital readmissions can worsen an already crowded healthcare system. However, the magnitude to which homelessness affects health service utilization among patients with mental health conditions remains unclear in the medical community. This study assessed the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental health conditions in an urban, safety-net hospital.MethodsWe conducted a secondary analysis of administrative data on all adult ED visits in 2012 in an urban safety-net hospital. Patient demographics, mental health status, homelessness, insurance coverage, level of acuity, and ED disposition per ED visit were analyzed using multilevel modeling to control for multiple visits nested within patients. We performed multivariate logistic regressions to evaluate if homelessness moderated the likelihood of mental health patients’ 30-day ED revisits and hospital readmissions.ResultsStudy included 139,414 adult ED visits from 92,307 unique patients (43.5±15.1 years, 51.3% male, 68.2% Hispanic/Latino). Nearly 8% of patients presented with mental health conditions, while 4.6% were homeless at any time during the study period. Among patients with mental health conditions, being homeless contributed to an additional 28.0% increase in likelihood (4.28 to 5.48 odds) of 30-day ED revisits and 38.2% increase in likelihood (2.04 to 2.82 odds) of hospital readmission, compared to non-homeless, non-mental health (NHNM) patients as the base category. Adjusted predicted probabilities showed that homeless patients presenting with mental health conditions have a 31.1% chance of returning to the ED within 30-day post discharge and a 3.7% chance of hospital readmission, compared to non-homeless patients presenting with mental health conditions (25.2%, 2.6%) and NHNM (7.7%, 1.5%).ConclusionHomeless patients presenting with mental health conditions were more likely to return to the ED within 30 days and to be readmitted to the hospital. Interventions providing housing might improve their overall care management and have the potential to reduce ED revisits and hospital readmissions.

Opioid Prescription Practices at Discharge and 30-Day Returns in Children with Sickle Cell Disease and Pain

Background: Acute pain episodes in children with sickle cell disease (SCD) represent a leading cause of readmissions. Lack of evidence-based guidelines contributes to variability in the management of children with SCD after hospitalization for acute pain. However, the impact of treatment variability on readmissions in this population has not been well studied. We examined prescription practices at time of discharge in children with SCD and acute pain to determine their impact on incidence of 30-day Emergency Department (ED) revisits and readmissions. We hypothesize that prescription of scheduled opioids after discharge for acute pain episodes is associated with lower 30-day ED revisits and readmissions when compared to the prescription of as needed or no opioids.Methods: We performed a single-institution, retrospective study of all patients with SCD aged 7 to 21 who were hospitalized or discharged from the ED with a diagnosis of acute pain episode from June 2009 to May 2014. Patients with ≥ 8 hospitalizations in a single year were excluded from the analysis. We reviewed demographic, treatment and discharge data from each encounter along with 30-day returns, defined as ED revisits and readmissions within 30 days of discharge. Between-groups comparisons for continuous variables were performed using the Mann-Whitney U test and categorical variables using the Chi-Square or Fisher's Exact test where appropriate. Independent predictors of 30-day returns were evaluated using multivariable logistic regression (IBM, SPSS v22).Results: We reviewed a total of 290 encounters (n=110, ED discharge; n=180, hospital discharge) in 97 patients (51% male, median 11.9 years old) during the 5-year period. Patients had hemoglobin SS or S/ß0 thalassemia in 209/290 (72%) encounters and were on hydroxyurea in 104/290 (36%). For hospitalizations (median length of stay 4 days), patients were treated with parenteral opioids in 159/180 (88%) encounters, most commonly by patient-controlled analgesia. Patients were prescribed opioids at the time of discharge in 259/290 (89%) encounters, more commonly at discharge from the hospital versus ED (96 vs. 79%, p < 0.01). The remaining patients were either prescribed non-steroidal anti-inflammatory drugs (NSAIDs) or a prescription was not given. Compared to as needed or no therapy, scheduled opioids were more frequently prescribed when discharged from the hospital versus ED (61 vs. 19%, p < 0.01). In total, 56/290 (19%) encounters resulted in 30-day ED revisits or readmissions after discharge from the hospital or ED. Compared to hospital discharges, discharge from the ED for acute pain was associated with a higher incidence of 30-day returns (OR = 2.7 [95% CI 1.5, 4.8], p < 0.01). Median number of days to return was also shorter for patients discharged from the ED versus hospital (4 vs. 11.5 days, p < 0.01). In general, we found no association between prescribed opioid frequency and incidence of 30-day returns. Prescription of scheduled opioids was similar between encounters that did or did not result in a 30-day ED revisit or readmission (46 vs. 48%, p = 0.8). Using multivariable logistic regression, we examined if other factors were associated with an increased incidence of 30-day returns. After discharge from the ED, the prescription of NSAIDs only, without opioids, was independently associated with a higher incidence of 30-day ED revisits but not readmissions. Neither 30-day ED revisits nor readmissions was affected by age, sex, genotype, or hydroxyurea use. After discharge from the hospital, none of these factors, including hospital length of stay or use of patient-controlled analgesia, were independently associated with 30-day ED revisits or readmissions.Conclusions: Variability exists in opioid prescription practices after discharge from the ED or hospital in children with SCD and acute pain episodes. Prescribed opioid frequency did not impact overall 30-day returns after discharge from the ED or hospital. After discharge from the ED, however, prescription of NSAIDs only, without opioids, was an independent predictor of higher 30-day ED revisits. Formalized studies to better understand factors that influence 30-day returns in children with SCD and acute pain are needed. Standardized approaches to outpatient opioid management after discharge and their impact on 30-day returns are also warranted in this population. DisclosuresNo relevant conflicts of interest to declare.

Frequent utilization of the emergency department for acute exacerbation of chronic obstructive pulmonary disease.

BackgroundLittle is known about patients who frequently visit the emergency department (ED) for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We aimed to quantify the proportion and characteristics of patients with frequent ED visits for AECOPD and associated healthcare utilization.MethodsWe conducted a retrospective cohort study of adults aged ≥40 years with at least one ED visit for AECOPD between 2010 and 2011, derived from population-based all-payer data of State ED and Inpatient Databases for two large and diverse states: California and Florida. Outcome measures were frequency of ED visits for AECOPD, 30-day ED revisits, subsequent hospitalizations, near-fatal events (AECOPD involving mechanical ventilation), and charges for both ED and inpatient services (available only for Florida) during the year after the first ED visit.ResultsThe analytic cohort comprised 98,280 unique patients with 154,736 ED visits for AECOPD. During the 1-year period, 29.4% (95% CI, 29.1%-29.7%) of the patients had two or more (frequent) visits, accounting for 55.2% (95% CI, 54.9%-55.4%) of all ED visits for AECOPD. In the multivariable model, significant predictors of frequent ED visits were age 55–74 years (vs. 40–54 years), male sex, non-Hispanic white or black race, Medicaid insurance (vs. private), and lower median household income (all P < 0.001). At the visit-level, 12.3% of ED visits for AECOPD were 30-day revisit events (95% CI, 12.1%-12.4%). Additionally, 62.8% of ED visits for AECOPD (95% CI, 62.6%-63.0%) resulted in a hospitalization; patients with frequent ED visits comprised 55.5% (95% CI, 55.2%-55.8%) of all hospitalizations. Furthermore, 7.3% (95% CI, 7.3%-7.5%) of ED visits for AECOPD led to a near-fatal event; patients with frequent ED visits accounted for 64.4% (95% CI, 63.5%-65.3%) of all near-fatal events. Total charges for AECOPD were $1.94 billion (95% CI, $1.90-1.97 billion) in Florida; patients with frequent ED visits accounted for $1.07 billion (95% CI, $1.04-1.09 billion).ConclusionsIn this large cohort study, we found that 29% had frequent ED visits for AECOPD and that lower socioeconomic status was significantly associated with a higher frequency of ED visits. Individuals with frequent ED visits for AECOPD accounted for a substantial amount of healthcare utilization and financial burden.

Seeking a Second Opinion: Use of the Same versus a Different Hospital for Patients Requiring Recurrent Emergency Department Visits

Implementation of the Centers for Medicare and Medicare Services Hospital Readmission Reduction Program in 2012 fueled research regarding recurrent hospital utilization. This research has primarily focused on inpatient utilization and has been limited by use of hospital-level datasets which do not allow for tracking of patients across institutions and use of large administrative datasets which lack detailed information about individual patient visits. Under-estimation of event rates is a common limitation of single institution or hospital system-based research. Rates of same versus different emergency department (ED) utilization, however, have not yet been documented. The primary objective of this study is to determine the proportion of 30-day ED revisits occurring at a differnt hospital as the index visit. We hypothesized that 20% of 30-day ED revisits occur at a different hospital than the index ED visit. This is a retrospective single-state cohort study using data describing all ED treat-and-release visits and 30-day return ED visits in Florida (FL) from July, 1 2010 - June 30, 2011. Data were obtained from the State Emergency Department Database (SEDD) and the State Inpatient Database (SID) of the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. All ED treat-and-release visits were followed forward to identify the next ED visit within 30 days and the hospital where that visit took place. ED treat-and-release without a subsequent 30-day visit were excluded from analysis. The primary outcome of the percent of ED revisits occurring at a different hospital as compared to the prior ED visit, per day, was modeled using beta regression. There were 1,156,441 ED discharges that had a subsequent 30-day ED revisit, with 33% of these return visits (386,368) occurring at a different hospital. The proportion of ED revisits occurring at a different hospital changed significantly in the first 72 hours after an index ED visit as compared to revisits occurring after 72 hours (z=-24.3, p<0.001). In unadjusted analysis, 64.5% of re-visits that occurred on the same day (day 0) as the index visit occurred at a different hospital than the index visit, 38.3% of re-visits on day 1 occurred at a different hospital, and 26.7% of revisits on day 2 occurred at a different hospital. After day 3, the proportion of ED revisits occurring at a different hospital than the index visit remained relatively constant at 30-31%. (Figure). This study found that a substantial proportion of ED revisits occur at different hospitals than the site of the index ED discharges, especially in the first 24-48 hours after an ED discharge. These findings highlight the importance of performing research regarding hospital utilization at a level larger than a single institution, as at least 30% of return visits are likely to be missed within a single institution. In addition, they emphasize the important of identifying effective methods to facilitate communication about patient care across institutions to maximize the delivery of safe and efficient emergency care.

Safety and Efficiency of Calcium Channel Blockers Versus Beta‐blockers for Rate Control in Patients With Atrial Fibrillation and No Acute Underlying Medical Illness

Many patients with atrial fibrillation (AF) are not candidates for rhythm control and may require rate control, typically with beta-blocking (BB) or calcium channel blocking (CCB) agents. Although these patients appear to have a low 30-day rate of stroke or death, it is unclear if one class of agent is safer or more effective. The objective was to determine whether BBs or CCBs would have a lower hospital admission rate and to measure 30-day safety outcomes including stroke, death, and emergency department (ED) revisits. This retrospective cohort study used a database from two urban EDs to identify consecutive patients with ED discharge diagnoses of AF from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with acute underlying medical conditions were excluded by predefined criteria. Patients managed only with rate control agents were eligible for review, and patients receiving BB agents were compared to those receiving CCB agents. The primary outcome was the proportion of patients requiring hospital admission; secondary outcomes included the ED length of stay (LOS), the proportion of patients having adverse events, the proportion of patients returning within 7 or 30 days, and the number of patients having a stroke or dying within 30 days. A total of 259 consecutive patients were enrolled, with 100 receiving CCBs and 159 receiving BBs. Baseline demographics and comorbidities were similar. Twenty-seven percent of BB patients were admitted, and 31.0% of CCB patients were admitted (difference = 4.0%, 95% confidence interval [CI] = -7.7% to 16.1%), and there were no significant differences in ED LOS, adverse events, or 7- or 30-day ED revisits. One patient who received metoprolol had a stroke, and one patient who received diltiazem died within 30 days. In this cohort of ED patients with AF and no acute underlying medical illness who underwent rate control only, patients receiving CCBs had similar hospital admission rates to those receiving BBs, while both classes of medications appeared equally safe at 30 days. Both CCBs and BBs are acceptable options for rate control.

242 Exploratory Analysis of 30-day Emergency Department Revisits and Readmissions by Heart Failure Patients

Admission for heart failure (HF) is associated with high post-discharge mortality, re-hospitalization, and cost. For Medicare beneficiaries, HF is the most common cause of admission and re-admission and consumes the greatest proportion of Medicare dollars. 30-day all-cause readmission of HF patients is a key national, publically reported quality measure, and is associated with financial penalties. Importantly however, HF patients have significant cardiac and non-cardiac co-morbid conditions, and may present to the emergency department (ED) for reasons other than HF. A better understanding of why recently discharged HF patients return to the ED is needed. This may present opportunities for targeted interventions to decrease re-admissions. To characterize the frequency and nature of 30-day ED revisits by patients with a past history of HF hospitalization Exploratory, retrospective, descriptive analysis of the Northwestern Enterprise Data Warehouse (EDW), a relational database of all medical data sources associated with a single, urban, academic, tertiary, level 1 trauma center, with ∼85,000 ED visits & ∼55,000 hospital admissions per year. All patients with a principal HF diagnosis from 1999 to 2009 were screened for a return ED visit during a consecutive 60-day period in 2009. Patients were categorized by principle discharge diagnosis: (HF, cardiovascular excluding HF, (CV non-HF), and other) as well as disposition from the ED: (discharge, observation, admission). HF admissions were further evaluated for 30-day ED re-visits. There were 691 ED encounters by 490 patients with a history of past HF admission over the last 10 years, during the 60-day exploratory period (mean visits per patient = 1.43). Approximately 25% of patients had at least 1 re-visit to the ED within 60 days. Acute HF (acute heart failure) accounted for 10.4% (n=72) of ED encounters, with 15.9% for CV non-HF and 73.7% for other reasons. Among subsequently admitted patients, 14.9% had a principal discharge diagnosis of HF, 17.4% for CV non-HF, and 67.7% other. For patients admitted with HF, nearly half (41.7%) had more than 1 re-visit during the 60-day study period. Amongst patients with at least 1 acute heart failure ED presentation, more than half (58.3%) of ED re-visits were for acute HF. Of the 24 index admissions for acute heart failure, 62.5% of patients returned to the ED within 30 days of discharge (21 re-visits to the ED by 15 patients). Of these 30-day ED re-visits, 23.8% were discharged home (approximately 1% were admitted to observation), while the remaining patients were re-admitted, 56.3% for acute heart failure, 12.5% were CV non-HF, and 31.3% for other reasons. In this exploratory analysis of patients with a past history of hospitalization for HF, acute HF is not the primary driver of presentation to the ED. However, in patients who initially present with acute heart failure, heart failure is the primary reason why they subsequently return to the ED. Nevertheless, a sizable proportion of 30-day re-admissions are for reasons other than acute heart failure.