Odds of return: a prospective study using provider assessment to predict short-term patient return visits to the emergency department

Objective Previous studies have assessed patient-level characteristics associated with emergency department (ED) return visits, but none have used provider assessment. We prospectively investigate whether clinical providers could accurately predict ED return visits. Methods Prospective cohort study. Setting Single academically affiliated urban county hospital. Participants Discharged ED patients over a 14-month period with a provider assessment of the likelihood of patient return within 7 days of ED discharge. Main outcome measures The primary outcome of interest was a return visit to the ED within 7 days. Additional outcome measures included a return visit within 72 hours and a return visit resulting in admission. We also measured the accuracy of provider gestalt, and provide measures of sensitivity, specificity, predictive values, and likelihood ratios. Results Of the 11 922 ED discharges included in this study, providers expected 2116 (17.7%) to result in a return visit within 7 days. Providers were much more likely to perceive a return visit if the patient left against medical advice (OR: 5.97, 95% CI: 4.67 to 7.62), or was homeless (OR: 5.69, 95% CI: 5.14 to 6.29). Patients who actually returned were also more likely to be homeless, English speaking and to have left the ED against medical advice on the initial encounter. The strongest predictor of a return visit at both 72 hours and 7 days in multivariable modelling was provider assessment (OR: 3.77, 95% CI: 3.25 to 4.37; OR: 3.72, 95% CI: 3.29 to 4.21, respectively). Overall sensitivity and specificity of provider gestalt as a measure of patient return within 7 days were 47% and 87%, respectively. The positive and negative likelihood ratios were 3.51 and 0.61, respectively. Conclusions Clinician assessment was the strongest predictor of a return visit in this dataset. Clinician assessment may be used as a way to screen patients during the index visit and enrol them in efforts to decrease return visits.

Automated summary

Clinician assessment was found to be the strongest predictor of a return visit in this study, with a sensitivity of 47% and specificity of 87%. This suggests that provider assessment may be a valuable tool in identifying patients who are at higher risk for return visits and enrolling them in programs to decrease the likelihood of such visits.