This single-site cross-sectional study by Lewis Hunter et al.1 addresses variation in admission rates for patients with similar clinical presentations who are evaluated in the emergency department (ED). The authors question whether non-clinical factors might explain this variability. Via survey responses, physicians reported the influence of medical acuity and non-clinical factors on their decisions to admit. Investigators found that greater than 90 % of admissions were influenced by non-clinical factors, with over half being strongly or moderately influenced. While this did not likely change the disposition of high-acuity patients, it may have been enough to provoke admission of some low-risk patients.

The authors wonder if this information could be used in the development of resources for emergency department patients that would allow safe discharge from the ED and assurance of follow-up testing. Decision rules with specific admission vs. observation vs. outpatient follow-up guidelines already exist for conditions such as syncope, chest pain, and TIA. Readily available follow-up for patients who are suitable for outpatient treatment could decrease the number of patients admitted based on concerns about follow-up or lack of rapid diagnostic testing. Syncope or observation units run by emergency departments could also help to reduce hospital admissions2 , 3.

While the study is difficult to generalize due to its short duration, single location, and lack of nighttime data points, the information is timely. Hospitals and physicians are being encouraged to bring down the cost of admissions and the overall cost of medical care to patients. Rather than cutting costs on admitted patients, this study suggests that reducing admissions by providing alternatives that address physician concerns could be a viable option. Prior investigations of the efficacy of case management and social workers in reducing admissions have been promising4. Perhaps the additional information provided by this study will encourage further progress in reducing the number of admissions of patients who could be followed up as outpatients.