Keith E. Kochar, M.D. was the lead author of a study published recently in Health Affairs that found that nearly 20 percent of older adults who had common operations needed emergency care within 30 days of their hospital stay. Kocher, a University of Michigan emergency physician, explains what can be gleaned from this data. | Interviewed by Bob Kehoe
What was the purpose of this study?
Kocher: We looked at the frequency of emergency department visits that occur within 30 days of a hospital discharge after a major surgery, including angioplasty, coronary artery bypass, hip fracture repair, back surgery, elective abdominal aortic aneurysm repair and colectomy. We were interested in how often ED visits occur within a month of these surgeries, how often this resulted in a readmission and the types of conditions that seem to drive these visits.
What were the key takeaways?
Kocher: The first is that ED visits, in general, are a window into hospital readmissions within 30 days. Looking at ED visits gives you a better sense of the unexpected care that these patients who experienced a hospital discharge may be seeing.
Second, most of these readmissions came through the ED, so maybe there's some type of care that can be delivered during that visit that could prevent a readmission. The ED visit could be used to re-establish care coordination or perhaps deliver treatment that will allow an alternative to readmission.
What types of hospital-level variation were evident in this study? What are the ramifications for costs and outcomes?
Kocher: We didn't look particularly at costs in this study, although there was a lot of variation in utilization of the ED, suggesting there might be large cost differences.
The outcomes we studied were ED use and readmission rates. The most striking variation in ED use was for patients who had a colectomy where there was a fourfold difference in readmissions between the best-performing group of hospitals and the worst-performing group. However, even the overall rate had a nearly twofold difference in ED use. Most likely there could be cost savings by improving the utilization rates at the worst-performing groups of hospitals. We didn't look at outcomes in terms of mortality or morbidity rates, but this would be an important follow-up question.
Why did the better-performing hospitals on colectomies have much lower readmission rates?
Kocher: Our study was not set up to address this, but you can make some educated guesses as to what may be driving these differences. We did our best to adjust for severity of illness and case mix, but there still may be some differences there that we can't tease apart from Medicare claims data.
Nevertheless, you would think that the same practices that hospitals are undertaking to affect their 30-day readmission rates likely would work on ED visits as well. For example, improving the discharge planning process — ensuring that patients get timely follow-up care; ensuring that patients and families understand their disease and have access to their prescribed medications — would similarly influence how frequently patients may end up requiring an ED visit.
Were there lessons in the data about care coordination?
Kocher: I think that's one of the major takeaway points from the study. ED visits are a common experience for many patients after being discharged from the hospital. The ED, therefore, provides an opportunity to think about an alternative to rehospitalization.
I'm a practicing emergency room physician and when I look across the landscape of health care, there really is not an equivalent outpatient venue of care that can provide the timeliness and intensity of care that an ED visit can even if it comes at times with long waits and some associated additional costs.
You can do timely diagnostic studies, provide treatments and reach out to specialty consultants and outpatient providers; it really has the potential of providing a venue where you can develop a care plan that may result in an alternative to a readmission.
What are some of the ways to improve the transition from inpatient to outpatient care?
Kocher: Our study didn't look at that question specifically and it's hard to know from the ED visit data we had what might have failed in the outpatient setting or what might have prevented the need for an ED visit after discharge.
We did look at the groups of diagnoses that seemed to be common among the patients who had an ED visit and many of the diagnoses involved cardiovascular and respiratory clinical conditions. Many of the types of surgeries that we studied also involved cardiovascular procedures like coronary artery bypass grafting, percutaneous coronary intervention or aneurism repairs, so you would think there would be a relationship. It is likely that many of the patients undergoing these surgeries had significant cardiovascular comorbidities to begin with that would require ongoing active management.
But even in other types of surgeries, such as back or hip fracture repair, there were many patients who had cardiovascular and respiratory problems driving their ED visits. That speaks to the fact that this Medicare population probably has some degree of baseline comorbidities, that major surgery is a significant insult to a patient's health and that there's a period of recovery that's to be expected. You have to be vigilant about managing their other conditions in addition to whatever is related to the surgery, particularly when the patient leaves the hospital.
Can the ED team play a more valuable role in post-surgical care coordination?
Kocher: Potentially there is a great opportunity. The ED venue can provide a range of diagnostic and treatment options that can be done in a timely fashion. Clinically, there are many things the emergency physician could provide for the care of these patients. The challenge comes more on the discharge-planning side.
Health policymakers and hospital administrators should realize that asking an individual emergency provider to be able to provide that kind of planning in addition to managing all of the other aspects of the patient's care within the context of a busy emergency department is probably unrealistic.
If you really want to impact this, you have to better resource the ED with other job descriptions like social workers and discharge planners because you're going to have to navigate through options like home health care, subacute nursing facilities and potentially observation care as an alternative to readmission. If you're willing to put those resources into the ED, then there's a real opportunity to think creatively about alternatives to readmission. That's certainly going to be expensive, but there may be a business model that supports that.
The Kocher File
Keith Kocher, M.D., M.P.H., is an assistant professor at the University of Michigan Health System's department of emergency medicine; he is board-certified in emergency medicine.
Lead author, "Emergency Department Visits After Surgery Are Common for Medicare Patients, Suggesting Opportunities to Improve Care", Health Affairs, September 2013
THE CHALLENGE AHEAD:
"We need to figure out which best practices to implement if we want to improve these rates of ED visits."
Emergency care organization and delivery; resource utilization within the ED; exploring the changing function and role of the ED within the U.S. health care system; understanding the dynamics underlying the decision of admission versus discharge for patients seen in the ED.