ObjectiveTo 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.DesignRetrospective cohort study.SettingClaims data from the US Medicare program, covering visits to an emergency department, 2007-12.ParticipantsNationally 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 measureDeath within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.ResultsAmong 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).ConclusionsEvery 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.

Objective To explore the feasibility of ecological momentary assessments (EMAs) as a tool to more accurately assess the level of bother from tinnitus. Study Design Longitudinal observational study. Setting Washington University Department of Otolaryngology - Head and Neck Surgery faculty practice plan. Subjects and Methods Twenty participants with moderately to severely bothersome tinnitus were enrolled. All participants owned a smartphone device and all communications were conducted via email, phone, and text messaging. Participants received four EMAs per day for two weeks via text message and a final survey on the fifteenth day. In each survey, participants recorded their level of tinnitus bother, their location at the time of response, their stress level, how they were feeling and what they were doing. Response rates as a proxy for the feasibility of the program. Results There were a total of 1120 surveys sent to 20 participants (56 surveys per participant) and 889 (79.4%) of the surveys were completed and returned. The median time to response from the moment of receiving text message was 7 minutes. The distribution of responses to the EMA question, "In the last 5 minutes, how bothered have you been by your tinnitus?" displayed both high between and within subject variability. At the end of 2 weeks, the median score on the THI was 37 with range 10–82 points; the median TFI was 43 with range 10– 82 points. Conclusion This study suggests bothered tinnitus patients will use smartphones as part of ecological momentary assessment.

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