The results of a new study show a substantial decline in mortality rates among Medicare beneficiaries visiting an emergency department from 2009 to 2016, especially among patients with high-severity conditions.

Healthcare continues to be in the spotlight as policymakers seek to improve care and its costs. Many policymakers who focus on emergency medicine (EM) characterize it as being overutilized by patients, excessive when it comes to performing tests, overly expensive, and prone to diagnostic errors.

Visits to the ED are getting more expensive, with the average price of a visit rising 135% from 2008 to 2017. Despite these rising costs, and ongoing efforts to encourage patients to see their primary care physician or use urgent care, 20% of people in the United States visit an emergency department each year. In fact, ED utilization rates have been increasing steadily since the 1990s, especially among those with Medicaid.

As ED visits have increased, hospital capacity has declined. The effects of these trends remain unclear; many worry that reduced admissions, increased discharges to home, and decreased hospital capacities may increase the risk of patient harm.

To address some of these concerns, a team of researchers looked at Medicare beneficiaries receiving care in U.S. emergency departments. They found that mortality within 30 days of an ED visit declined recently, especially among the highest-severity patients.

Furthermore, ED doctors were admitting fewer patients to the hospital and sending more patients home instead. The findings suggest that the quality of the nation’s ED care, while over utilized and getting more expensive, is improving over time.

Retrospective Study Results Suggest Improvements in ED Outcomes and Efficiency in Care

Laura Burke, MD, MPH, an emergency medicine physician at Beth Israel Deaconess Medical Center (BIDMC), and colleagues performed a retrospective study that looked at more than 15 million U.S. emergency department visits among traditional Medicare beneficiaries from 2009 to 2016.

The team evaluated several aspects of ED outcomes. The researchers compared the number of hospital admissions compared with discharges to home, for example, and looked at whether the admission/discharge ratio was changing over time.

Burke and colleagues examined whether the changes in mortality rates for these patients were similar across different types of hospitals, such as urban and rural hospitals, small community hospitals, and large academic medical centers. The researchers also looked at whether trends in admissions and mortality rates were the same for the sickest ED patients as for the healthiest.

They found that mortality rates within 30 days of an ED visit improved by 23% from 2009 to 2016. Extrapolated to national ED visit rates among Medicare recipients, this would translate to nearly 200,000 fewer deaths in 2016 than if mortality rates had stayed at 2009 levels. The fact that mortality rates improved despite sending more patients home and admitting fewer to the hospital suggests that ED physicians are improving efficiency of care and outcomes.

Furthermore, nonprofit, major teaching hospitals and urban hospitals saw the more significant improvement in mortality over time.

The results of the study suggest declining admission and mortality rates are due to improved outcomes and efficiency of care in U.S. emergency departments.

“When researchers and policymakers studying emergency care look only at trends in patients who are discharged from the ED, as they commonly do, they may miss the fact that this pool of discharged patients is becoming increasingly complex over time as more patients who would’ve been hospitalized in the past are now being managed in the ED and sent home rather than deferring additional testing and treatment to the hospital setting,” said Burke. “Additionally, the fact that these gains were not equally distributed across hospitals means that there should be greater attention paid to those hospitals that have lagged behind and understanding how we can best help all hospitals improve.”

The researchers published their results in JAMA Internal Medicine.