Hospital-Based Acute Care 30 Days Postdischarge

One factor increasingly being used as a marker of the quality of care provided by hospitals to inpatients is the facility’s rate of readmission. The quality of the discharge process during the transition of care from an inpatient to an outpatient setting can also be measured by the readmission rate. Hospital readmission within 30 days of discharge is common and costly and is often related to the index hospitalization, according to researchers.

Researchers have noted that previous assessments of readmission rates have included too narrow a focus that may have created an “incomplete picture of the use of hospital-based acute care following discharge.” Visits to the emergency department (ED) that not do result in readmission may also be indicators of poorly executed transitions in care. Policy makers are increasingly utilizing postdischarge ED visits as an additional measure in evaluating care delivery methods.

Noting that there are limited data on use of the ED for hospital-based acute care in the 30 days following inpatient discharge, researchers recently conducted a prospective study to determine the degree to which ED visits and hospital readmissions contribute to overall use of acute care services in the postdischarge period. They reported study results in JAMA [2013;309(4):364-371].

The 3 primary study outcomes during the 30-day postdischarge period were: (1) visits to the ED that did not result in hospital readmission (treat and release); (2) hospital readmissions from any source; and (3) a combined measure of ED visits and hospital readmissions termed hospital-based acute care.

The researchers analyzed data on patients ≥18 years of age who were discharged between July 1, 2008, and September 30, 2009, from acute care hospitals in California, Florida, and Nebraska. The data were recorded in the Healthcare Cost & Utilization Project state inpatient and ED databases.

The final study cohort included 5,032,254 index hospitalizations among 4,028,555 unique patients. During the 30-day postdischarge period, 17.9% of discharges resulted in at least 1 acute care encounter, 7.5% of discharges were followed by at least 1 ED encounter, and 12.3% by at least 1 readmission. For every 1000 discharges, there were 97.5 ED treat-and-release visits and 147.6 hospital readmissions during the 30-day postdischarge period. ED visits comprised 39.8% of the 1,233,402 postdischarge acute care encounters.

The number of visits to the ED that did not result in inpatient readmission ranged from 22.4 encounters per 1000 discharges for breast malignancy to 282.5 encounters per 1000 discharges for uncomplicated benign prostatic hypertrophy. Among the highest volume discharges, the most common reason patients returned to the ED was always related to the index hospitalization.

The researchers cited 4 limitations to the study findings: (1) data from only 3 states were utilized in the analysis; (2) the study only measured acute care that took place in the ED or inpatient hospital setting, creating the possibility that the results underestimated the use of acute care following hospital discharge; (3) the data did not identify patients who died following hospitalization; and (4) the use of claims-based administrative data carries the possibility of errors in recoding of diagnoses, resulting in the misclassification of encounters.

In conclusion, the researchers commented, “After discharge from acute care hospitals in 3 states, ED visits within 30 days were common among adults and accounted for 39.8% of postdischarge hospital-based acute care visits. Improving care transitions should focus not only on decreasing readmissions but also on ED visits.”