title: Outcomes in patients with heart failure treated in hospitals with varying admission rates: population-based cohort study.
abstract: OBJECTIVE
  Hospital admission rates for patients with heart failure (HF) presenting for emergency department (ED) care vary, and the implications of direct discharge home from the ED are unknown. We examined whether patients treated in hospitals with low admission rates exhibit higher rates of repeat ED visits, hospital readmissions and death.
  
  
  METHODS
  We divided EDs into low-, medium- and high-admission-rate tertiles by their standardised HF admission rate in Ontario, Canada. Among adults (≥18 years) with HF discharged from an ED between April 2004 and March 2010, we evaluated the primary outcomes of repeat ED visits or hospitalisations for HF, and secondary outcomes, which included death, within 30 days stratified by HF admission-rate tertile.
  
  
  RESULTS
  89 878 patients with HF presented to low- (n=29 929), medium- (n=30 900) or high- (n=29 049) admission-rate institutions, with hospitalisation rates of <67%, 67-75% and >75%, respectively. Among 28 175 ED-discharged patients, the multivariable-adjusted HR for repeat ED visit or hospitalisation for HF at low-admission-rate institutions was 1.18 (95% CI 1.07 to 1.29, p<0.001) compared with high-admission institutions. Similarly, the HR for repeat ED visits for HF was 1.28 (95% CI 1.14 to 1.44, p<0.001) at low-admission hospitals. Compared with discharged patients in the high-admission-rate tertile, adjusted HR for 30-day mortality was 1.19 (95% CI 0.95 to 1.47) at low-admission-rate hospitals. The HRs for all of the above outcomes were not significantly increased at medium-admission-rate hospitals.
  
  
  CONCLUSIONS
  Patients seeking care at institutions with lower rates of HF admission showed higher rates of repeat ED visits or hospitalisations after previous ED discharge.
authors: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Women's College Hospital Institute for Health Systems Solutions and Virtual Care, University of Toronto, Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors: R Sacha
authors: RS
authors: Bhatia
authors: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors: Peter C
authors: PC
authors: Austin
authors: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors: Therese A
authors: TA
authors: Stukel
authors: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Department of Emergency Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
authors: Michael J
authors: MJ
authors: Schull
authors: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors: Alice
authors: A
authors: Chong
authors: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
authors: Jack V
authors: JV
authors: Tu
authors: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Peter Munk Cardiac Centre and the Joint Department of Medical Imaging of the University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors: Douglas S
authors: DS
authors: Lee
mesh_terms: D000328:Adult; D000368:Aged; D004636:Emergency Service, Hospital; D005260:Female; D006333:Heart Failure / Q000401:mortality / Q000628:therapy*; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D010359:Patient Readmission / Q000706:statistics & numerical data*; D012189:Retrospective Studies
keywords: Emergency Department; Health Services Research; Quality Improvement