A new study on Medicare patients dying soon after emergency department discharges raises questions about staffing and treatment at rural hospitals and other providers who are under pressure to reduce health care costs.
More than 10,000 Medicare patients who do not have life-threatening illnesses die each year in the US within seven days of being released from emergency departments, according to the study, published in the BMJ. Those hospitals with the lowest inpatient admission rates, often hospitals in rural areas, had much higher rates of unexpected deaths.
The study’s lead author said that while the data reflect a fraction of Medicare patient deaths, the finding raises questions about the adequacy of hospital resources in rural and underserved areas and whether the US government’s quest to cut costs — and reduce inpatient admissions from ERs — is also cutting out 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 that shouldn’t go home,” said Dr. Ziad Obermeyer, an emergency medicine physician, and professor at Harvard Medical School.
Under the Affordable Care Act, hospitals are under financial pressure to deliver care more efficiently and reduce unnecessary admissions that drive up costs. That has encouraged hospitals to explore alternatives to admitting patients from the ER, such as monitoring them remotely or providing more care at home or in outpatient settings.
Dr. Rade Vukmir, a fellow of the American College of Emergency Physicians, said the study “definitely illustrates that there is a problem.” He said that “admission and discharge strategies” used by Medicare and private insurers influence decision-making, even though most doctors serve as strong advocates for their patients. Manpower and technical resources also vary widely among providers, he said, as do the medical problems that afflict their patients.
“The study brings forth that providing … proper resources and pathways to deliver care will generate the best outcomes,” Vukmir said. “That process should be cooperative with health care providers, insurers, and patients.”
The study examined care delivered to about 16 million Medicare patients between 2007 and 2012. It looked at generally healthy patients, excluding those with life-limiting conditions as well as patients living in nursing homes or undergoing hospice care.
Among discharged patients, about 0.12 percent died within seven days, equating to just over 10,000 deaths annually. Heart attacks and associated cardiovascular problems accounted for the most common cause of death among patients.
The rate of admissions from the ER varied widely among hospitals. The researchers found that hospitals in the lowest quintile of admission rates discharged 85 percent of their patients, compared to 44 percent for those in the highest quintile.
Hospitals with low admissions had a much higher rate of unexpected deaths — 3.4 times that of hospitals with the highest rate of admissions. Obermeyer noted that the disparity in outcomes was not explained by the level of illness in the hospitals’ patient populations, as the high-admission-rate hospitals tended to see sicker patients.
“It doesn’t seem that the deaths are due to random chance,” he said. “There is something different going on in those low-admissions-rate hospitals.”
That difference, he said, is not necessarily attributable to provider error, however. A wide array of factors could be influencing the outcomes, such as limited staffing at poorer hospitals and fewer transportation options in rural areas to allow patients get follow-up care.
Part of the issue could also be related to protocols related to specific conditions. In cases where patients were diagnosed with chest pain, fewer unexpected deaths occurred, the researchers found. But death rates were higher among patients sent home with confusion, shortness of breath, or those diagnosed with pneumonia who were deemed healthy enough to be discharged.
Obermeyer also said that one of the leading causes of unexpected deaths among the Medicare patients studied was narcotic overdoses. “Those were largely in people who came in with musculoskeletal issues — back pain and other injuries,” he said. “We’re finding the signature of that problem” among Medicare patients as well.
Matt Birnholz, MDPeer
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