Higher ED Admission Rates Do Not Reduce Mortality

TOPLINE:

Patients of emergency department (ED) physicians with higher admission rates showed no improvement in 30-day mortality, despite their physicians ordering more tests and contributing to longer hospital stays. This suggests that higher admission propensities may not translate into better patient outcomes.

METHODOLOGY:

• In this cross-sectional study, researchers evaluated 2,137,681 patient visits (mean patient age, 63 years; 9.8% women) to 2098 physicians across 105 Veterans Affairs EDs between 2011 and 2019.
• Overall, 37.5% of patient visits involved a chief complaint of chest pain, 38.4% involved shortness of breath, and 30.9% involved abdominal pain.
• The main outcomes included admission rates, short inpatient stays (

TAKEAWAY:

• Approximately 41% of visits resulted in an admission, and of those admitted, 19.4% were admitted for less than 24 hours. The mean 30-day mortality rate was 2.5%, and the mean number of radiology and laboratory tests per visit was 1.1 and 7.9, respectively.
• Substantial variation in admission rates was seen among physicians working in the same ED. For instance, the differences in admission rates for chest pain, shortness of breath, and abdominal pain were 24.0, 19.1, and 13.6 percentage points, respectively, for physicians in the 90th vs 10th percentiles.
• Physicians with higher admission rates ordered a higher number of radiology and laboratory tests per visit. Moreover, patients admitted by these physicians spent more time in the hospital within 30 days of their ED visit and were more likely to have short inpatient stays.
• Researchers found no relationship between physician admission rates and patients’ prior health status or 30-day mortality rate.

IN PRACTICE:

“We found substantial variation in admission rates across physicians working in the same ED,” the authors wrote. 

“Multiple factors may contribute to the decision to admit a patient to the hospital, including psychosocial, insurance, or circumstantial factors not captured in the study…However, it is clear that interclinician practice variation accounts for numerous admissions that could have been safely avoided. Innovative payment models and quality improvement programs that incentivize standardized admission decision-making for common conditions are needed to reduce low-value care in the ED,” authors of an accompanying editorial wrote.

SOURCE:

The study was led by Stephen Coussens, PhD, David Geffen School of Medicine at University of California, Los Angeles. It was published online on December 23, 2024, in JAMA Internal Medicine.

LIMITATIONS:

The observational nature of the study meant that unobserved clinical confounders not captured in electronic health records (EHR) data could not be ruled out. The study population had a higher percentage of male patients and was conducted within the Veterans Affairs system, which has comprehensive EHR that ensures access to detailed medical history and different ED staffing patterns than non-VA settings. These factors may limit the generalizability of findings to other healthcare settings.

DISCLOSURES:

The study was supported in part by a Veterans Affairs Health Systems Research Center for the Study of Healthcare Innovation, Implementation & Policy Locally Initiated Project. The authors reported no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.