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Outcomes in patients with heart failure treated in hospitals with varying admission rates: population-based cohort study
  1. R Sacha Bhatia1,2,3,4,
  2. Peter C Austin1,3,
  3. Therese A Stukel1,3,
  4. Michael J Schull1,4,5,
  5. Alice Chong1,
  6. Jack V Tu1,3,4,6,
  7. Douglas S Lee1,3,4,7
  1. 1Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  2. 2Women's College Hospital Institute for Health Systems Solutions and Virtual Care, University of Toronto, Toronto, Ontario, Canada
  3. 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  4. 4Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  5. 5Department of Emergency Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
  6. 6Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
  7. 7Peter Munk Cardiac Centre and the Joint Department of Medical Imaging of the University Health Network—Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Douglas S Lee, Senior Scientist, Institute for Clinical Evaluative Sciences, Division of Cardiology, University Health Network, Associate Professor of Medicine, University of Toronto, ICES, Rm G-106, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5; dlee{at}


Study objectives 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.

Discussion Patients seeking care at institutions with lower rates of HF admission showed higher rates of repeat ED visits or hospitalisations after previous ED discharge.

  • Health Services Research
  • Emergency Department
  • Quality Improvement

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