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As emergency department (ED) visits increase, there is growing pressure to minimize hospital admissions associated with these visits. Using Medicare data, researchers analyzed trends in mortality within 30 days after an ED visit among patients aged ≥65 years from 2009 to 2016. Analyses were stratified by ED disposition and predicted 30-day mortality and were adjusted for age, comorbidities, and other predictors of mortality.
The analysis included over 15 million visits to 4828 acute care EDs. The ED discharge rate increased from 53.6% in 2009 to 56.7% in 2016. Unadjusted 30-day mortality decreased from 5.1% to 4.6%, even though illness severity increased over time; adjusted mortality decreased from 5.7% to 4.4%. Among discharged patients, mortality decreased over time in all analyses. For admitted patients, unadjusted mortality increased slightly (9.5% to 9.9%) but adjusted mortality actually decreased. Decreases in adjusted mortality were seen across hospital types but were slightly larger in teaching, nonprofit, and urban hospitals.
Burke LG et al. Trends in mortality for Medicare beneficiaries treated in the emergency department from 2009 to 2016. JAMA Intern Med 2019 Nov 4; 1; [e-pub]. (https://doi.org/10.1001/jamainternmed.2019.4866)
Comment
It seems too good to be true for sicker patients with fewer admissions to have lower mortality. Plausible explanations are that systems of emergency care are improving, effective alternatives to inpatient admission are being used more often, or coding changes have resulted in a decrease in documented illness severity. However, even if the last is true, it seems unlikely to completely account for the observed decreases in admissions and mortality. These findings support the notion that we should continue to try to find the right place to care for patients after their ED visits, whether in a hospital, observation unit, skilled nursing facility, or even at home with clinicians making home visits.