Of patients presenting to the emergency department (ED) only a minority are admitted to inpatient care, while the vast majority are evaluated, treated, and discharged for ongoing care in the community.1 A significant proportion of discharged patients will return to the ED within 30 days, with more than three-quarters being discharged a second time.2 An estimated 25% of ED visits in the USA may be managed in the community at a savings up to $4.4 billion annually3; thus, subjects re-presenting to the ED typifies a targeted population- where interventions preventing unnecessary visits may lead to reduced healthcare costs and improved quality of care.
On this basis, Hastings et al. performed a pragmatic, randomized controlled trial of more than 500 veterans discharged from a single ED identified as high-risk for return based on comorbidities and past ED usage.3 They evaluated the implementation of a structured, nursing-led, telephone support program focused on improving transitions of care, chronic disease management, and education, compared with routine care. The study benefits from a strong protocolized intervention and strict study methods, producing high internal validity.
Authors successfully identified high-risk subjects as the overall rate of return was high, but found no difference in the primary outcome of repeat ED visits within 30 days between routine care and intervention groups. Notable secondary outcomes included higher rates of PCP follow up, and greater engagement with weight loss, diabetes, and telehealth management programs compared to control subjects.
Although disappointing at face value, this study highlights the complexities of addressing the unmet health care, psychosocial, and chronic disease management needs driving excess ED usage. Although there was increased engagement in chronic management services, ED and hospital admissions were unchanged up to 6 months of follow-up, indicated that reevaluation for new conceptual models to affect ED usage should be considered.
It should be recalled that many, if not most, ED presentations are unlikely to be preventable even with the upmost access and support. The authors, many hailing from the “Center of Innovation to Accelerate Discovery and Practice Transformation,” should be congratulated for doing just that.
Hastings SN, Smith VA, Weinberger M, Schmader KE, Olsen MK, Oddone EZ. Emergency department visits in Veterans Affairs medical facilities. Am J Manag Care 2011;17:e215-223.
Hastings SN, Stechuchak KM, Coffman CJ, Mahanna EP, Weinberger M, Van Houtven CH, Schmader KE, Hendrix CC, Kessler C, Hughes JM, Ramos K, Wieland GD, Weiner M, Robinson K, Oddone E. Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial. J Gen Intern Med. 2019. https://doi.org/10.1007/s11606-019-05319-6
Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Aff 2010;29(9):1630–1636.
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Simpson, T.F. Capsule Commentary on Hastings, et. al., Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial. J GEN INTERN MED 35, 401 (2020) doi:10.1007/s11606-019-05387-8