Putting Quality Into Quality Indicators

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!

A February 16, 2016 study in JAMA on in-hospital outcomes and costs among patients hospitalized during a return visit to the ED by Sabbatini et al (2016;315[7]:663-671) provides compelling evidence that the number of unscheduled return visits to an ED within 30 days should not be considered a quality measure of ED care. Though the findings of this important study should provide reassurance that emergency physicians (EPs) and EDs provide quality care, the way the paper’s conclusion was framed makes one wonder whether we EPs tend to judge ourselves too harshly.

Sabbatini et al analyzed Healthcare Cost and Utilization Project data on 9,036,483 patients ages 18 years or older who visited 424 hospital EDs in Florida and New York from February through November 2013, and found that of the 7,278,124 patients who were initially discharged, 1,205,865 returned to the ED within 30 days. Of the returning patients, the 86,012 who were admitted to the hospital within 7 days of the initial visit had significantly lower rates of in-hospital mortality, ICU admissions, and mean costs of hospitalization, but slightly higher inpatient lengths of stay, compared with the 1,609,145 patients who had been admitted on their initial ED visits. Similar outcomes were observed for patients who returned to the ED and were admitted within 14 and 30 days of their initial ED visits. In contrast, patients readmitted upon return to the ED after hospital discharge had higher rates of inpatient mortality and ICU admissions, longer lengths of stay, and higher costs during their repeat hospitalizations compared with the hospitalizations of patients admitted during their initial ED visit with no return ED visits after discharge.

To James Adams, MD, in an editorial accompanying the study (JAMA. 2016;315[7]:659-660), these numbers suggest that neither misdiagnosis nor inadequate treatment on an initial ED visit appear to be the primary causes of return visits to EDs that result in admissions and do not indicate a failure of ED care. However, the authors of the paper—mostly EPs—framed their conclusion somewhat differently, writing “these findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit,” implying, perhaps, that there are ED quality-of-care deficits but that the number of return ED visits followed by admissions does not capture them. An alternatively worded, accurate conclusion about the findings might be “hospitalizations associated with return visits to an ED do not appear to indicate a quality-of-care deficit.”

An unfortunate choice of words or an overly critical view of EP performance? In this issue of Emergency Medicine, there are other examples suggesting that EPs’ perception of their performance—and perhaps by extension, satisfaction with their roles—may be problematic.

In “Allegations: Current Trends in Medical Malpractice, Part 2” (pages 158-162), McCammon and Jennings note that EP’s perception of their malpractice risk ranks higher than that of other physicians’ perception of their risks, despite the findings of a 1991-2005 review of malpractice claims ranking EM in the middle of all specialties with respect to annual risk of claims. “What’s Hot and What’s Not in Our National Organizations: an Emergency Medicine Panel” reports on the most important issues facing emergency medicine (pages 163-166). ACEP President Jay Kaplan, MD, begins by noting that “EM leads all specialties in the frequency of physician burnout.”

Why the pessimism, the unfounded concerns over malpractice risk, the acceptance of possible deficits in the quality of emergency care we provide that may or may not actually exist? After years of listening to unsubstantiated concerns about malpractice suits and quality issues from administrators and regulators, along with dire warnings about EM burnout from other specialists, are we actually beginning to believe them? Doing so would only perpetuate these myths and possibly even discourage the type of high-quality study demonstrated by the efforts of Sabbatini et al. Emergency physicians fulfill an increasingly important central role in health care and have much to be proud of, so let’s insist on evidence-based findings and not accept half-truths or less from anyone. As an essential specialty practiced by highly valued specialists, we deserve better!