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February 2, 2017

Study: Hospitals with low ED admission rates typically have higher unexpected death rates

Daily Briefing

    Hospitals with low ED admission rates tend to have higher rates of unexpected deaths than hospitals with higher admission rates, according to a study published Wednesday in BMJ, Casey Ross reports for STAT News.

    For the study, researchers reviewed claims data from 2007 through 2012 on roughly 16 million Medicare beneficiaries to identify the proportion of beneficiaries who died within seven days of being discharged from an ED. The researchers excluded data on beneficiaries with life-limiting conditions, as well as those who were living in nursing homes or who were receiving hospice care.

    Study findings

    The researchers found that about 0.12 percent of discharged patients unexpectedly died within seven days. According to the researchers, that equates to more than 10,000 deaths annually.

    The researchers also found that the rate at which hospitals admitted patients from the ED varied considerably among the facilities. Hospitals in the lowest quintile of ED admission rates discharged 85 percent of patients, while hospitals in the highest admission quintile discharged 44 percent of patients. According to the researchers, hospitals with the lowest ED admission rates often were located in rural areas.

    Overall, the researchers found that the unexpected death rate was 3.4 percent higher among hospitals with low ED admission rates when compared with hospitals that had higher admission rates.

    Study lead author Ziad Obermeyer, an emergency medicine physician and professor at Harvard Medical School, said illness levels among the hospitals' patient populations did not explain the disparity in patient outcomes. However, he added that the disparity could be related to limited staffing at lower-income hospitals and fewer transportation options in rural areas, which could curb patients' access to care.

    The most common causes of death were heart attacks and related cardiovascular problems, the researchers found. However, they found that fewer unexpected deaths occurred among discharged patients who were diagnosed with chest pain than among discharged patients who were diagnosed with:

    • Confusion;
    • Pneumonia; or
    • Shortness of breath.

    According to Obermeyer, narcotic overdoses also were a leading cause of unexpected death among patients included in the data. He said those deaths largely occurred among patients "who came in with musculoskeletal issues—back pain and other injuries."


    Obermeyer said the findings raise questions about the adequacy of hospital resources, particularly among hospitals in rural and underserved areas, as well as whether efforts to reduce inpatient admissions from the ED are affecting essential care. "There's no doubt there's a lot of unnecessary hospital admissions, but this study suggests there's also avoidable harm from sending people home [who] shouldn't go home," he said.

    Rade Vukmir, a fellow of the American College of Emergency Physicians, said the findings "definitely illustrat[e] that there is a problem." He added, "The study brings forth that providing … proper resources and pathways to deliver care will generate the best outcomes" (Ross, STAT News, 2/1; Obermeyer et al., BMJ, 2/1).

    Reducing hospital mortality with the help of an EHR


    Electronic health records have a role to play in mortality reduction. Computerized practitioner order entry (CPOE) and electronic order sets are the key EHR capabilities that can help reduce hospital mortality, but changes in process, culture, and individual behavior are also necessary.

    In this report, we present six hospital case studies to illustrate the impact of EHRs on mortality, identify the mechanisms by which EHRs could help reduce hospital mortality, and zero in on the specific functionality that might have the greatest impact.

    Read the research briefing

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