Repeat ED visits for acute heart failure suggest need for better outpatient care
Almost one-third of acute heart failure syndrome patients seen in hospital emergency departments (EDs) in Florida and California during 2010 had ED visits during the following year, findings that suggest a lack of appropriate outpatient care. A study by Massachusetts General Hospital (MGH) investigators also finds that patients with frequent ED visits for the syndrome accounted for more than half of all such ED visits and hospitalizations, contributing to significant health care costs.
"The high proportion of patients with frequent ED visits reflects the failure of current measures to manage heart failure symptoms," says Kohei Hasegawa, MD, MPH, MGH Department of Emergency Medicine, corresponding author of the report in Circulation: Cardiovascular Quality and Outcomes. "Our finding also suggests that quality improvement efforts focusing only on hospital admissions may provide an incomplete picture of the utilization of health care services by discounting the importance of pre-admission ED visits."
The paper's authors note that acute heart failure syndrome (AHFS) – an increase in symptoms that requires urgent care – accounts for more than 675,000 ED visits and one million hospitalizations in the U.S. each year, incurring around $31 million in costs. Most ED visits for the syndrome are considered preventable through continuing high-quality outpatient care, and the reduction of hospitalizations for AHFS through prevention and treatment is one of the goals of the Department of Health and Human Service's Healthy People 2020 program. Since previous studies of the care of patients with AHFS have focused on hospital admissions, the MGH team set out to study characteristics of patients with frequent ED visits for AHFS.
The investigators analyzed information from state databases covering ED visits and inpatient admissions in Florida and California during 2010 and 2011. Of the more than 113,000 adult patients with at least one ED visit for AHFS during 2010, nearly 70 percent had no repeat visit for the syndrome during the next 12 months. But almost 34,800 patients – 30 percent of the total – returned to the ED because of AHFS at least once in the following year. Those individuals were more likely to be black or Hispanic, to be covered by Medicaid and to be low-income. Patients with frequent ED visits accounted for more than 55 percent of all ED visits for AHFS during the study period, including those that led to hospital admission, and 58 percent of visits that required mechanical respiratory support.
"We estimate that prevention of repeat ED visits by high-quality outpatient care of heart failure symptoms would reduce almost 62,000 ED visits and more than 52,000 hospital admissions in both states, saving more than $1 billion in Florida alone," says Hasegawa. "The association of frequent ED visits with several markers of lower socioeconomic status suggests that factors such as limited access to outpatient services, financial distress and differences in personal health behaviors may act as barriers to appropriate follow-up care, but we need further studies of the role of these factors to develop better preventive measures."
An assistant professor of surgery at Harvard Medical School, Hasegawa adds, "The U.S. Center for Medicare and Medicaid Services policies directed towards reducing the utilization of health care services should also consider the implications of frequent ED visits for AHFS and for other chronic conditions. Previous studies by our team had very similar findings – patients with frequent ED visits accounting for disproportionate service utilization – in patients with asthma or with chronic obstructive pulmonary diseases."