Almost one-third of patients who visit the emergency department (ED) for acute heart failure will return two or more times within a year, results published online Aug. 19 showed. Could readmissions penalties exacerbate the problem?
Kohei Hasegawa, MD, MPH, of Massachusetts General Hospital in Boston, and colleagues wrote in Circulation: Cardiovascular Quality and Outcomes that much research has focused on heart failure readmissions. “Frequent ED visits better reflect the failure of more prevention-oriented care and, accordingly, may serve as a patient-centric metric,” they proposed.
They designed a retrospective population-based study using two databases from two states, Florida and California, to track ED trends. The state databases included unique encrypted patient-level identifiers that allowed the researchers to conduct a one-year follow-up on a sample of 113,033 patients who presented to the ED in 2010 with acute heart failure. The two states hold about 18 percent of the U.S. population.
The primary outcome was the frequency of ED visits for acute heart failure during the 365-day period after the index visit. They found that 30.8 percent of the patients visited the ED two or more times within a year, which they defined as frequent visits. Overall, 86.4 percent of ED visits led to hospitalization.
Patients at highest risk of frequent ED visits were more likely to be non-Hispanic black or Hispanic and with a lower socioeconomic status.
Frequent visitors accounted for 55.4 percent of all acute heart failure ED visits, with patterns similar in both states. They also accounted for 58.1 percent of near-fatal events.
In Florida, charges for acute heart failure ED visits and inpatient services totaled more than $3 billion, with more than half attributed to frequent visitors. “If recurrent ED visits after the index visit could be prevented, up to 62,458 ED visits and 53,234 hospitalizations would have been saved annually in the two states alone,” Hasegawa et al calculated.
They observed that penalties that withhold Medicare payment to hospitals with higher than expected readmissions for heart failure unintentionally may create incentives to treat patients in the ED or in observation units. “Even if readmission rates decrease, higher use of ED resource may lead to fragmented care and consequently contribute to duplication of services, conflicting care recommendations and higher costs,” they warned.
The researchers wrote that the high proportion of frequent ED visits for acute heart failure reveal a failure in patient management and highlight the need to re-evaluate secondary prevention efforts and healthcare policies.