Early death after discharge from emergency departments: analysis of national US insurance claims dataBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j239 (Published 01 February 2017) Cite this as: BMJ 2017;356:j239
- Ziad Obermeyer, assistant professor1 2 3,
- Brent Cohn, research assistant3,
- Michael Wilson, instructor1 3,
- Anupam B Jena, associate professor2,
- David M Cutler, professor4
- 1Department of Emergency Medicine, Harvard Medical School, Boston, MA 02115, USA
- 2Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA
- 3Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- 4Department of Economics, Harvard University, Cambridge, MA 02138, USA
- Correspondence to: Z Obermeyer
- Accepted 23 December 2016
Objective To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients.
Design Retrospective cohort study.
Setting Claims data from the US Medicare program, covering visits to an emergency department, 2007-12.
Participants Nationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded.
Main outcome measure Death within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.
Results Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)—3.4 times higher than hospitals in the highest fifth (0.08%)—despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7).
Conclusions Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.
We thank David Peak for participating in the expert panel to classify groups of ICD codes into acute and chronic life limiting diagnoses and for his thoughtful advice on this project; and Tim Putnam for providing extremely valuable insights into emergency care in rural hospitals.
Contributors: ZO designed the study, wrote the manuscript, and obtained funding. BC and ZO performed data analysis. DMC, ABJ, and MW contributed to the design of the study and writing of the manuscript. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.
Funding: This research was supported by a grant from the Office of the Director of the National Institutes of Health (DP5 OD012161) to ZO and a grant from the Laura and John Arnold Foundation. This research was independent from funders. The funder had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The views presented here are those of the authors and not necessarily those of the Laura and John Arnold Foundation, its directors, officers, or staff.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: This study was approved by the institutional review boards of Partners HealthCare and the National Bureau of Economic Research.
Data sharing: No additional data available.
Transparency: The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained
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