Health Policy Journal Club, Health Policy, Health Care Administration

Health Policy Journal Club: Bounce-Backs

Post-ED Follow-Up May Identify High-Risk Patients

Ensuring patients discharged from the emergency department have adequate visit follow-up care is a vital component of the treatment plan. There is limited data available on the frequency of follow-up obtained after an ED visit or on outcomes of discharged patients.

A study conducted by Lin et al. sought to address this gap by examining the frequency of ambulatory follow-up in patients discharged from the ED, and, more important, whether follow-up had any impact on post-discharge outcomes. The study consisted of a cohort of Medicare beneficiaries ages 65 and older who were seen and discharged following ED visits from 2011-2016.

The 30-day cumulative incidence of mortality was 1.4% in this cohort of patients. Essentially one out of every 100 Medicare patients deemed fit to go home during an index ED visit ended up dying within 1 month.

Patients who obtained ambulatory follow-up had a 1% (HR, 1.01; 95% CI, 1.003-1.01; P < .001) higher likelihood of subsequent ED visit within 30 days, and a 22% (HR, 1.22; 95% CI, 1.21-1.23; P < .001) higher likelihood of an inpatient stay during that time. Follow-up was also associated with a 51% (HR, 0.49; 95% CI, 0.49-0.50; P < .001) lower risk of mortality within 30 days of ED discharge.

Though these numbers may seem paradoxical, they illustrate the value of the post-discharge ambulatory follow-up. Patients may have been more likely to have a repeat ED visit – and even a hospitalization – within 30 days, but this also decreased their overall risk of death. In essence, the ambulatory visit may have been serving as the safety net as it is intended to be.

Implications for EM
This study highlights the need to avoid perpetuating the negative stigma held towards an ED bounce-back. When a patient returns to the ED within 30 days, the visit may be an indicator that the system is working as intended. It ensures that the patient who truly needed additional care is identified, stabilized, potentially hospitalized, and perhaps saved. Emergency physicians must continue to work to establish ambulatory follow-up for any patients we discharge, and we must also change the way we perceive bounce-back patients. These are potentially ill patients who have given us a second chance to evaluate their symptoms.

On a larger level, however, we must also advocate for systems and policy changes to make setting up outpatient follow-up as easy as possible for all patients. 


Article: Lin MP, Burke RC, Orav EJ, Friend TH, Burke LG. Ambulatory Follow-up and Outcomes Among Medicare Beneficiaries After Emergency Department Discharge. JAMA Netw Open. 2020;3(10):e2019878.

Ambulatory follow-up care is frequently recommended after an emergency department (ED) visit. However, the frequency with which follow-up actually occurs and the degree to which follow-up is associated with post-discharge outcomes is unknown.

To examine the frequency and variation in ambulatory follow-up among Medicare beneficiaries discharged from U.S. EDs and the association between ambulatory follow-up and post-discharge outcomes.

Cohort study of 9,470,626 ED visits to 4,728 U.S. EDs among Medicare beneficiaries aged 65 and older from 2011 to 2016 who survived the ED visit and were discharged to home used Kaplan-Meier curves and proportional hazards regression.

Data analysis was conducted from December 2019 to July 2020.

Exposures: Ambulatory follow-up after discharge from the ED.

Main outcomes and measures: Postdischarge mortality, subsequent ED visit, or inpatient hospitalization within 30 days of an index ED visit.

The study sample consisted of 9,470,626 index outpatient ED visits to 4,684 EDs; most visits (5,776,501 [61.0%]) were among women, and the mean (SD) age of patients was 77.3 (8.4) years. In this sample, the cumulative incidence of ambulatory follow-up was 40.5% (3,822,133 patients) at 7 days and 70.8% (6,662,525 patients) at 30 days, after accounting for censoring and for mortality as a competing risk. Characteristics associated with lower rates of ambulatory follow-up included beneficiary Medicaid eligibility (hazard ratio [HR], 0.77; 95% CI, 0.77-0.78; P < .001), Black race (HR, 0.82; 95% CI, 0.81-0.83; P < .001), and treatment at a rural ED (HR, 0.75; 95% CI, 0.73-0.77; P < .001) in the multivariable regression model.

Ambulatory follow-up was associated with lower risk of postdischarge mortality (HR, 0.49; 95% CI, 0.49-0.50; P < .001) but higher risk of subsequent inpatient hospitalization (HR, 1.22; 95% CI, 1.21-1.23; P < .001) and ED visits (HR, 1.01; 95% CI, 1.00-1.01; P < .001), adjusting for visit diagnosis, patient demographic characteristics, and chronic conditions.

In this cohort study of Medicare beneficiaries discharged from the ED, nearly 30% lacked ambulatory follow-up at 30 days, with variation in follow-up rates by patient and hospital characteristics. Having an ambulatory follow-up visit was associated with a higher risk of subsequent hospitalization but a lower risk of mortality. Ambulatory care access may be an important driver of clinical outcomes after an ED visit. 

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.