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Large number of deaths among Medicare patients occur soon after ED discharge

Despite relatively young age and no documentation of life-limiting illnesses, more than 10,000 Medicare patients die soon after discharge from the ED each year, according to findings published in the BMJ.

“A growing number of patients visit [EDs] every year: nearly 20% of the U.S. population each year,” Ziad Obermeyer, MD, MPhil, from the department of emergency medicine at Harvard Medical School, and colleagues wrote.

“Small studies point to non-trivial numbers of patients who die unexpectedly after discharge home from the [ED], but these studies rely on individual chart reviews or data from single health systems,” they added. “It is difficult to assess generalizability of these findings or to shed light on how variation across hospitals might shape the quality and safety of emergency care.”

Obermeyer and colleagues sought to determine the occurrence of early death after ED discharge and evaluate the underlying causes of variation in risk. They studied claims data of ED visits from 2007 to 2012 of a nationally representative 20% sample of Medicare fee-for-service beneficiaries. Patients in nursing facilities, aged 90 years and older, receiving palliative or hospice care or with a diagnosis of a life-limiting illness were excluded from the study. Patients who were transferred or admitted to the ED as inpatients were also excluded. The investigators defined early death as death within 7 days after ED discharge.

Results indicated that early death occurred in 0.12% of discharged patients (n = 10,093; mean age at death, 69 years). Atherosclerotic heart disease (13.6%), myocardial infarction (10.3%) and chronic obstructive pulmonary disease (9.6%) were the leading causes of death. Although hospitals with low admission rates tended to serve healthier populations, the highest rates of early death (0.27%) were observed in hospitals ranking in the lowest fifth of rates of inpatient admission from the ED. In comparison, hospitals in the highest fifth had a 3.4 times lower rate of early death (0.08%). Significant reductions in risk were associated with minimal increases in admission rate.

Multivariate analysis revealed that considerably fewer deaths occurred in EDs with higher volumes of patients (OR = 0.84; 95% CI, 0.81- 0.86), as well as higher charges for visits (OR =0.75; 95% CI, 0.74-0.77). Compared with other ED visits, altered mental status (RR = 4.4; 95% CI, 3.8-5.1), dyspnea (RR = 3.1; 95% CI, 2.9-3.4) and malaise/fatigue (RR = 3; 95% CI, 2.9-3.7) were more common among early deaths, according to the researchers.

“Many Medicare beneficiaries die shortly after discharge from [EDs], despite no obvious life-limiting illnesses recorded in their claims,” Obermeyer and colleagues concluded. “Hospitals with low admission rates and low patient volumes, and patients with high risk diagnoses at discharge, could represent targets for clinical research and quality improvement efforts.”

“Further research is needed to explore whether these deaths were preventable,” they added.

Previous research has found that 25% of hospital readmissions are potentially preventable. – by Alaina Tedesco

Disclosure: The researchers report receiving support from the Office of the Director of NIH and the Laura and John Arnold Foundation.