Equivalent Mortality Regardless of Decision to Admit Versus Not to Admit in the 30 Days After an Index ED Visit
Clinical question: Do patients who are admitted to the hospital benefit from hospitalization, especially when the likelihood a given patient is admitted is highly dependent on the relative propensity of the ED physician to admit patients of similar acuity?
Background: Usually, the decision to admit a patient to the hospital is made by ED physicians, and there is significant variability between individual ED physicians in how likely they are to admit a given patient. The authors questioned whether there are differences in outcomes in patients being cared for by ED physicians with high propensity to admit versus low propensity to admit. The corollary to this, from a hospitalist perspective, is how well we inpatient physicians are matching the range of hospitalization services and supports to the range of acuity of patients who are admitted to our service.
Study design: A national, multi-site, retrospective, cross-sectional study
Setting: 105 Veterans Affairs (VA) EDs
Synopsis: Using national VA data encompassing more than 2 million ED visits seen by more than 2,000 ED physicians, patients were split into cohorts by the following chief concerns: chest pain, shortness of breath, or abdominal pain. Within each cohort, several variables were controlled for, including time of arrival, location within the ED, and Emergency Severity Index, to normalize the patient’s health status prior to the ED visit. Patients cared for by high-rate-of-admission ED physicians had similar rates of mortality as those cared for by low-rate-of-admission ED physicians (regardless of whether they were admitted or not) at every time point evaluated after ED visit through one year. Patients cared for by high-propensity-to-admit ED physicians were more likely to have more tests ordered in the ED, to be admitted, to have a hospital stay less than 24 hours, and to spend more days (2 versus 1.5) in an ED or hospital in the 30 days after the index ED visit (indicating that high-acuity care was not simply deferred).
Bottom line: Variability in admission practices among individual ED attendings can lead to increased resource utilization without corresponding improvements in outcomes or reductions in return visits. Hospitalists address this variability by triaging admissions and tailoring length of stay based on the risks and benefits of continued hospitalization. Future studies may explore a more proactive role for hospitalists in ED triage and care coordination to promote early, safe discharges directly from the ED.
Citation: Coussens S, Ly DP. Variation in emergency department physician admitting practices and subsequent mortality. JAMA Intern Med. 2025;185(2):153–160. https://doi.org/10.1001/jamainternmed.2024.6925.
Dr. Ostfeld-Johns is an assistant professor of clinical pediatrics and internal medicine with a primary appointment in the section of hospital medicine in the department of pediatrics at Yale School of Medicine in New Haven, Conn.