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.