Is there method in the madness: observation vs. full admission

Author: M. Fernanda Bellolio, MD (@mfbellolio)

Last night a 68-year old male presented to the Emergency Department with chest pain. His pain lasted 45 minutes and resolved with 2 nitroglycerin tablets. He has history of coronary artery disease, stents placed within the past 2 years and a previous myocardial infarction. He has hypertension and diabetes. He was pain free by the time he arrived to the ED and hemodynamically stable.

We had a discussion with him regarding his risk, goals and preferences and decided for admit for acute coronary syndrome rule out. Our ED observation unit is full, so we admit him to the Cardiology floor for “observation” and continue acute coronary syndrome rule out with serial troponins and possible stress test vs angiogram.

We signed out the patient to the cardiology floor. Then the patient refused to stay.

"I cannot stay if is observation, please admit me as an inpatient instead”, “I already have too many bills to pay”.

What do we know of observation status and inpatient admission? Is the care provided the same? Why do we need to know as providers?

In an effort to reduce short- stay admissions, many institutions are admitting patients under “observation” status. Patients admitted for observation care are considered outpatients despite that observation care can be provided in a regular hospital floor bed or in a specific area of the ED (ED observation units).

In the study “Observation or inpatient: Impact of patient disposition on outcomes and utilization among emergency department patients with chest pain” we collaborated with OptumLabs and AARP and using administrative claims data we compared a cohort of patient presenting with chest pain and admitted for “observation” versus “short-inpatient stay”.

Objectives and methods

• Compare healthcare utilization including:
  • Coronary angiography
  • Percutaneous coronary intervention (PCI)
  • Rehospitalization
  • Acute myocardial infarction (AMI) within 30-days
• Among patients presenting to the Emergency Department (ED) with chest pain from 2010-2014 admitted as short inpatient (≤2 days) versus observation (in ED observation and in-hospital observation).
• Patients having myocardial infarction during the index visit were excluded.
• One-to-one propensity-score matching and logistic regression were used.

What we found?

• Incidence of myocardial infarction within 30-days of ED evaluation for chest pain is low (1-2 per 1,000), and most patients can be safely discharged home.
• There were higher rates of cardiac catheterization and coronary intervention (PCI) among those admitted as a short inpatient compared to observation, while the incidence of subsequent myocardial infarction within 30-days was similar.

We concluded that:

• Patients with chest pain placed under “observation” or “short inpatient” had different healthcare utilization after propensity matching by comorbidities, age, gender, and year of ED visit.
• Short inpatients had higher healthcare utilization, with higher rates of angiography and PCI when compared to those under observation.
• Despite these differences in healthcare utilization, the incidence of subsequent AMI within 30-days was similar.
• This means that patients that were admitted to a higher level of care (inpatients) received “more care”, but this did not result in improved acute myocardial infarction rates.
• This might represent an opportunity to direct future research to evaluate if this represents over-utilization for the inpatients, or under- utilization for the observation group.

The full article is available in Academic Emergency Medicine:

http://onlinelibrary.wiley.com/doi/10.1111/acem.13116/full

Why we need to know?

To comply with Medicare, Medicaid, managed care plans and commercial payer regulations related to observation or inpatient status. The determination of whether the hospital stay is designated as inpatient or observation should not affect the quality of care; however, it has billing and discharge planning implications.

Observation versus inpatient makes a difference for the amount of out of pocket cost for patients. This is particularly important for patients on Medicare, and it is critical for patients that will be placed on a skilled nursing facility after the hospital stay.

For inpatients:

• Medicare Part A (Hospital Insurance) covers inpatient hospital services.
• Medicare Part B (Medical Insurance) covers most services for inpatient. Patients pay 20% of the Medicare-approved amount for doctor services after paying the Part B deductible.

For observation:

• Part B covers outpatient hospital services. Generally, this means patients pay a copayment for each individual outpatient hospital service. This amount may vary by service. (Note: The copayment for a single outpatient hospital service can’t be more than the inpatient hospital deductible. However, the total copayment for all outpatient services may be more than the inpatient hospital deductible.)
• Part B also covers most of the doctor services. Patient pay 20% of the Medicare-approved amount after the Part B deductible.
• Prescription and over-the-counter medications administered in the outpatient setting (like the emergency department), aren’t covered by Part B.

More information:

• ACEP utilization review FAQ: https://www.acep.org/Clinical---Practice-Management/Utilization-Review-FAQ/
• Medicare booklet on observation vs admission: https://www.medicare.gov/Pubs/pdf/11435.pdf

Image from flickr by Aussie~moss

Modifications were made

Licensed under CC BY 2.0