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Dr. Christopher Caulfield

Approximately 25% of all patients admitted through the ED at UNC Medical Center are cared for by a hospitalist. Hospitalist physicians are well positioned to evaluate the need for admission for patients referred from the ED and new data shows hospitalization is not always the right choice.

“We wanted to look at specific patient populations that come to the ED who are referred to a hospitalist for an admission but are deemed to be safe for discharge without hospitalization,” said Christopher A. Caulfield, MD, from the division of hospital medicine and lead author of a new paper published in the American Journal of Managed Care.

“Characterizing these patients into diagnosis groupings will help hospitalists and ED physicians understand that many patients can ultimately be discharged home from the ED rather than be hospitalized.”

The study identifies 178 diagnoses for patients discharged from the UNC Medical Center ED after referral for hospitalist admission from April, 2011 to April, 2014. The most common diagnosis was unspecified chest pain (34.1%), followed by unspecified abdominal pain (9.0%). The 6 most common diagnosis groups–chest pain, syncope, abdominal pain, nausea/vomiting, and sickle cell disease–made up 68.2% of the total patient encounters analyzed. After categorization, chest pain was the largest diagnosis group (38.2%).

Caulfield says diagnostic testing and procedures puts patients at risk for procedural complications. “An unnecessary diagnostic test can lead to additional testing and evaluations that may not be warranted. For example, a patient with low risk chest pain could be hospitalized for a stress test that may result in a false positive result, leading to further testing and procedures. In addition, that patient may leave the hospital with the financial responsibility of a large medical bill.”

“This scenario was not the focus of our study, but it highlights the possible unnecessary costs and risks associated with an unnecessary hospitalization. We focused on the idea that hospitalization could be prevented all together as there are patients who are appropriate to send home with close outpatient follow-up. These patients have a low likelihood of return to the ED or need for hospitalization in the future.”

Among 710 emergency department (ED) discharges for 670 patients referred for hospitalist admission: Four of 5 patients did not return to the ED and 9 of 10 patients did not require hospitalization within 30 days. Chest pain was the most common diagnosis.

Those with alcohol-related diagnoses, abdominal pain, and sickle cell disease with crisis were more likely to return to the ED, whereas those presenting with chest pain were less likely. Those with Medicare and Medicaid were more likely to return to the ED compared with those who were privately insured.

“We want people to realize that hospitalization is not always the right choice for patients who present to the ED. We cite several articles that discuss the risks of hospitalization, but we want readers to realize that discharging certain subsets of patients home from the ED, with close follow up, may be more beneficial for patients in that 80% of these patients did not return to the ED within 30 days, 90% of these patients did not require hospitalization within 30 days, and ultimately there were no unexpected deaths within 30 days.”

In addition to Caulfield, the study included John Stephens, MD; Zarina Sharalaya, MD; Jeffrey P. Laux, PhD; Carlton Moore, MD, MS; Daniel E. Jonas, MD, MPH; and Edmund A. Liles Jr, MD.