Emergency department revisits and costs higher than previously reported

1. From an observational study, revisits to emergency departments (ED) were higher than previously reported when considering presentations to institutions other than the initial site.

2. Additionally, revisit costs exceeded total costs from initial visits.

Evidence Rating Level: 3 (Average)   

Study Rundown: Revisits to an emergency department (ED) after initial treatment and discharge can potentially further strain healthcare systems. Previous research on revisit rates has focused on return visits to the same institution and have largely neglected cost analysis. To better measure the burden of ED revisits, this observational study assessed the frequency of and costs of revisits within 30 days across institutions. Using data from 5 states, the overall revisit rate within 3 days was about 8%, with almost a third of these revisits involving a different hospital than the initial encounter. At 30 days, the cumulative revisit rate was nearly 20%, many of which were at different institutions. Patients with Medicaid and self-pay coverage had the highest revisit rates compared to private insurance. Financial data revealed that costs of revisits can exceed the total cost of initial ED visits (for those with and without return visits). This study is strengthened by the use of a government database that allows for capturing of revisits outside the index institution, but is limited by the availability of data from only 5 states with incomplete financial reporting. Furthermore, the data does not allow for differentiation of clinical appropriateness for revisit. Overall, the ED revisitation rate and associated costs may be higher than previously measured.

Click to read the study, published today in Annals of Internal Medicine

Relevant Reading: Emergency Department Bouncebacks: Is Lack of Primary Care Access the Primary Cause?

In-Depth [retrospective cohort]: This study used encounter data for years 2006-2010 from the Healthcare Cost and Utilization Project. Data for 5 states (Arizona, California, Florida, Nebraska, Utah, Hawaii) included linked patient information, which allowed for tracking across institutions. Primary outcomes were daily and cumulative revisit rates, as well as cost for 3 days and 30 days following the index visit, and cost numbers represent data from Florida alone. Overall revisit rates within 3 days were 8.2% (95%CI 8.0 to 8.4%) for ages 18-44, 8.5% (95%CI 8.3 to 8.7%) for ages 44-64, and 7.8% (95%CI 7.6 to 7.9%) for those older than 65. At 30 days, the cumulative revisit rate was 19.9% with 28% of those at different institutions. Medicaid and self-pay patients (10.1% and 9.0%, respectively) had higher rates than private insurance patients (6.3%), and public hospitals had the highest rates (9.0%) compared to for-profit and private nonprofit hospitals (8.3% and 8.0%, respectively). Approximately 89% of revisits had the same primary diagnosis as during the index visit. The most common revisit diagnosis was skin and subcutaneous tissue infection (23.1%, 95%CI 22.3 to 23.9%). Revisit costs in Florida at 30 days were 117% of the cost for all index ED visits.

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