As part of the triple aim, there is a very concerted effort to develop markers of high-quality care in all of American health care. The Centers for Medicare and Medicaid Services has developed reporting and payment targets for physicians and for hospitals, and a significant amount of reimbursement will be based on performance measures.

For more than 20 years, emergency physicians have been faced with hospital programs that report ED return visits, usually in a 72-hour window. Multiple studies have characterized the return visit rate as a poor marker of quality. Definitions have been unclear, and strategies to address associated factors have been very nonspecific.

One study of return visits focused on the patient-driven factors.¹ Emergency medicine is a specialty driven by timeliness of care and perceived patient need. Research has found that patients used the emergency department based on their perception of good value. Patients returned due to perceived inability to access timely follow-up care, needed care that was not available, and concern about the progression of the original medical problem. The majority of patients had a primary care physician but felt that resources needed for completion of care would be accessed in a more timely manner by returning to the emergency department.

Patient-driven factors for return visits are highlighted in the book Quality Matters: Solutions for a Safe and Efficient Emergency Department by Shari Welch, MD. Her suggestion is that emergency departments should intentionally and systematically return high-risk patients to ensure the best patient outcomes.

From a quantitative basis, the Centers for Disease Control and Prevention National Hospital Ambulatory Medical Care Survey data in this area have always been enlightening. The latest data are from the 2014 reporting year:

• About 5.7 percent of ED visits were made by patients who had been seen in the same emergency department in the preceding 72 hours.
• About 4.8 percent of ED visits were for “follow-up.”
• In about 3 percent of ED visits resulting in hospital admission, the patient had been seen in the same emergency department within the prior 72 hours.

This is a very important baseline history. Other studies have found return rates to any emergency department in a particular region average 7.55 percent over a five-year period.^2,3 These authors reflect on the utility of regional health information exchanges to further track and improve the care of patients having return visits and further improve the value of the emergency department in providing care for patients with ongoing medical issues that did not result in inpatient care on the initial visit.

Reasons for return visits to the same emergency department may include a scheduled revisit for wound check, the worsening of an original medical problem, a complication from the treatment, repeat diagnostics or treatment, the desire for reassurance, and many others. When the patient visits another emergency department, some other factors may be causative. It may reflect movement to a higher level of care. It may also reflect an initial patient encounter that was unsatisfactory, ended with a concern that wasn’t addressed, or was followed by a complication.

With these many factors in the mix, it is very likely that return frequency does not accurately reflect quality.

There is benefit to timely data collection and sharing among emergency departments. The Emergency Department Benchmarking Alliance is a large group of high-performance American emergency departments that share a commitment to quality and development of performance measures that has served its member hospitals and the industry since 1994. However, the return visit issue is not an area that the alliance has identified as an important quality or performance measure, even with repeated efforts to differentiate “scheduled” and “unscheduled” return visits.

In the development of the Clinical Emergency Data Registry, ACEP evaluated potential quality measures that could be utilized. The return visit issue was discussed and dismissed. ACEP’s decision may portend the eventual death of this quality measure for both research and performance comparison.

Some payer-supported work is critical of ED work that results in a bounce back and admission.⁴ However, recent systematic studies concluded that return visits resulting in hospital admission are not an indicator of poor care.^5,6 These ED visits may be a fruitful source of cases for quality improvement activities, but they rarely identify deficiencies in initial ED care and are associated with shorter, lower-cost admissions when they do occur. It was suggested that high-quality care occurs when patients are seen in the emergency department, undergo appropriate testing and treatment, and are released because they do not meet admission criteria. The discharge instructions to “return if the condition worsens or if there are complications of treatment” result in less cost and exposure to hospital comorbidities for many persons and, on average, shorter stays for patients who choose to return.

A strategy of encouraging return ED visits may be very prudent. That is likely a satisfier for ED patients and their families, and it accurately reflects the value of having emergency departments available for patients, especially for return visits.

References

1. Rising KL, Padrez KA, O’Brien M, et al. Return visits to the emergency department: the patient perspective. Ann Emerg Med. 2015;65(4):377-386.e3
2. Shy BD, Kim EY, Genes NG, et al. Increased identification of emergency department 72-hour returns using multihospital health information exchange. Acad Emerg Med. 2016;23(5):645-649.
3. Shy BD, Loo GT, Lowry T, et al. Bouncing back elsewhere: multilevel analysis of return visits to the same or a different hospital after initial emergency department presentation [published online ahead of print Sept. 27, 2017]. Annals Emerg Med.
4. Duseja R, Bardach NS, Lin GA, et al. Revisit rates and associated costs after an emergency department encounter: a multistate analysis. Ann Intern Med. 2015;162(11):750-756.
5. Sabbatini AK, Kocher KE, Basu A, et al. In-hospital outcomes and costs among patients hospitalized during a return visit to the emergency department. JAMA. 2016;315(7):663-671.
6. Cheng J, Shroff A, Khan N, et al. Emergency department return visits resulting in admission: do they reflect quality of care? Am J Med Qual. 2016;31(6):541-551.