Factors associated with low-acuity hospital admissions in a public safety-net setting: a cross-sectional study

Abstract

Background: Given system-level focus on avoidance of unnecessary hospitalizations, better understanding admission decision-making is of utility. Our study sought to identify factors associated with hospital admission versus discharge from the Emergency Department (ED) for a population of patients who were assessed as having low medical acuity at time of decision. Methods: Using an institutional database, we identified ED admission requests received from March 1, 2018 to Feb 28, 2019 that were assessed by a physician at the time of request as potentially inappropriate based on lack of medical acuity. Focused chart review was performed to extract data related to patient demographics, socioeconomic information, measures of illness, and system-level factors such as previous healthcare utilization and day/time of presentation. A binary logistic regression model was constructed to correlate patient and system factors with disposition outcome of admission to the hospital versus discharge from the ED. Physician-reported contributors to admission decision-making and chief complaint/reason for admission were summarized. Results: A total of 349 (77.2%) of 452 calls resulted in admission to the hospital and 103 (22.8%) resulted in discharge from the ED. Predictors of admission included age over 65 (OR 3.5 [95%CI 1.1-11.6], p = 0.039), homelessness (OR 3.3 [95% CI 1.7-6.4], p=0.001), and night/weekend presentation (OR 2.0 [95%CI 1.1-3.5], p = 0.020). The most common contributing factors to the decision to admit reported by the responding physician included: lack of outpatient social support (35.8% of admissions), homelessness (33.0% of admissions), and substance use disorder (23.5% of admissions). Conclusions: Physician medical decision-making regarding the need for hospitalization incorporates consideration of individual patient characteristics, social setting, and system-level barriers. Interventions aimed at reducing unnecessary hospitalizations, especially those involving patients with low medical acuity, should focus on underlying unmet needs and involve a broad set of perspectives.

Changing Admission Patterns in Pediatric Emergency Departments during the COVID-19 Pandemic in Italy Were Due to Reductions in Inappropriate Accesses

“…However, focusing on costs alone does not consider the perverse effects on the rational use of resources, considering that these patients are often examined as a priority by the attending physician to exclude a severe condition and to discharge the patient as quickly as possible. Furthermore, every admission is associated with risks, and it is highly improbable that the experience of attending the ED would improve quality of life for the patient [24,25].…”

Hospital variation in admissions for low back pain following an emergency department presentation: a retrospective study

“…Clinicians are ultimately responsible for deciding whether to admit a patient, although hospital factors such as culture and policies might shape clinicians’ behaviour. Social factors, lack of outpatient social support, were also not present in our model, but seem to be an important contributing factor to emergency doctors’ decision to admit a patient [ 40 ]. This seems particularly relevant in the Australian context, as patients living in areas classified as being of low socioeconomic status make up more than half of non-urgent triage category presentations in EDs [ 2 ].…”

Prevalence, determinants and practical implications of inappropriate hospitalizations in older subjects: A prospective observational study

“…The method we used to identify inappropriate admissions pointed out the crucial role of the ED physician, allowing to answer both these questions: i) how frequently does a physician admit a patient to the hospital despite the lack of sufficient medical acuity requiring hospitalization and ii) which are the main reasons contributing to this decision? [53]. Although such a binary distinction may represent an over-simplification and might underestimate the rate of inappropriate hospitalization (ED physicians might have been cautious to label as inappropriate or avoidable the hospitalization they decided), for its ability to capture the nuances of clinician judgment this method likely reflects in a practical way the actual absence of immediately available alternative settings of chronic care.…”