Hospital Revisits Often Follow Observation Stays

At 30 days post-discharge, one in five observation status patients had a revisit, such as an ED stay, another observation stay, or inpatient stay.

Medicare patients often revisit the hospital after observation stays, according to Yale researchers. The high revisit rate points to a “hidden vulnerability” among observation status patients and also suggests that hospitals should make changes to the care they provide, the researchers said.

The study was published online June 20 in The BMJ.

Observation stays have increased in recent years as alternatives to inpatient stays, but little research has been done to assess their associated outcomes for patients, according to first author Kumar Dharmarajan, M.D., assistant professor of medicine.

Researchers analyzed nationally representative data on Medicare beneficiaries from 2006 to 2011, calculating hospital revisit rates and mortality rates in the 30 days following discharge from an observation stay. They compared the data with the same outcomes for Medicare recipients who had an initial inpatient stay or received care in the ED.

Specifically, they looked at Medicare fee-for-service beneficiaries aged 65 or over discharged after 363,037 index observation stays; 2,540,000 index ED treatment-and-discharge stays; and 2,667,525 index inpatient stays.

The research team found that a significant number of observation stay patients returned to the hospital.

“We found that in the 30 days after discharge, one in five patients had a revisit, such as an ED stay, another observation stay, or inpatient stay,” said Dharmarajan in a statement. “Half of those revisits were for inpatient care and these revisits increased over time.”

Averaged over the study period, 30-day rates of any hospital revisit were similar after ED treatment-and-discharge stays (19.9%) and observation stays (20.1%). Rates of 30-day mortality were the same (1.8% for both).

“As revisit rates are similar after emergency department and observation stays, strategies shown to enhance emergency department transitional care may be reasonable starting points to improve post-observation outcomes,” the authors write.

Rates of any hospital revisit (21.8%) and death (5.2%) were highest after discharge from inpatient stays.

“The findings are important because a revisit rate of one in five suggests that patients are vulnerable after discharge to adverse health events,” Dharmarajan said. “Strategies designed to improve care for patients after inpatient stays may also be helpful after observation stays.”

Hospitals are now required to present the Medicare Outpatient Observation Notice (MOON) advisory in writing and verbally to Medicare beneficiaries who receive at least 24 hours of hospital services under outpatient status. The MOON advisory alerts Medicare beneficiaries about the potential coverage consequences of inpatient vs. outpatient status at hospitals.