Which unscheduled return visits indicate a quality-of-care issue?

BACKGROUND: The rate of unscheduled return visits is often used as a quality-of-care indicator in EDs, although its validity is not yet fully established. Our aim was to identify the characteristics of return visits that may be attributed to problems in quality of care. METHODS: Retrospective paired review of medical charts in a random sample of return visits during the 72 hours following discharge from the ED in three hospitals of Andalusia, Spain in 2013. Charts were reviewed by senior medical physicians to determine which return visits reflected quality-of-care problems. Time frame for return visit, index and return visit acuity, disposition and diagnosis were compared with determine which variables were associated with a quality problem. Sensitivity and specificity for each variable to indicate a quality problem were determined. RESULTS: We studied the causes of 895 return visits, finding that 65 (7.3%) were due to inadequate quality of care in the index visit. Potentially avoidable return visits were more common in more severely ill patients, in those with greater severity in the return than in the index visit and in patients hospitalised after the return. The combination of this three variables presented sensitivity 66% and specificity 68% in identification of quality-related returns. CONCLUSIONS: The overall level of return visits cannot be considered a valid indicator of quality of care. However, certain specific variables, including the level of severity of the patient's condition or the discharge destination following the return visits, could be considered valid in this respect.

[Causes of 72-hour return visits to hospital emergency departments]. / Causas de los retornos durante las 72 horas siguientes al alta de urgencias.

OBJECTIVES: The return-visit rate has been suggested as a measure of emergency department quality of care. We aimed to identify the reasons for emergency revisits and the percentage of returns related to problems with quality of care in the previous visit. MATERIAL AND METHODS: Cross-sectional observational study of clinical records for a random sample of unscheduled returns within 72 hours of discharge from the emergency departments of 3 hospitals attending a population of nearly 3 million in the Spanish province of Malaga. The records were reviewed by 2 data collectors, who assigned a reason for revisits according to a standardized classification. RESULTS: A sample of 1075 emergency revisits were reviewed; 895 met the inclusion criteria. The most common reasons for revisits were the persistence or progression of disease (48.8%), an unrelated new problem (9.3%), and referral from a hospital that did not have the required specialized service (8.6%). Reasons attributable to the patient accounted for 14.5% of the revisits; 15.2% were attributable to health care staff errors, 9.2% to system organization, and 61.1% to the disease process. CONCLUSION: Most emergency department revisits are related to the progression of the disease that led to the first visit. Only a small percentage can be linked to diagnostic or treatment errors in the previous visit.

OBJETIVO: La tasa de retornos a urgencias (RU) se ha propuesto como indicador de calidad asistencial en servicios de urgencias hospitalarios (SUH). Nuestro objetivo fue conocer las causas de los RU y la proporción de RU relacionados con problemas de calidad asistencial en la urgencia previa. METODO: Estudio observacional transversal con auditoría de historias clínicas sobre una muestra aleatoria de RU durante las 72 horas siguientes al alta de un SUH de tres hospitales que prestan atención a casi un millón de habitantes de la provincia de Málaga. Revisión independiente por pares y asignación de la causa del RU según una clasificación estandarizada. RESULTADOS: Se analizó una muestra de 1.075 RU, de los que 895 cumplían los criterios de inclusión. Las causas de RU más frecuentes fueron la persistencia o progresión de la enfermedad (48,8%), la aparición de un nuevo problema no relacionado (9,3%) y la derivación a otro hospital por no disponer del especialista necesario (8,6%). Las causas se agruparon en 14,5% atribuibles al paciente, 15,2% a los profesionales sanitarios, 9,2% a la organización del sistema y 61,1% a la enfermedad. CONCLUSIONES: La mayor parte de los RU se debe a la evolución de la enfermedad que motivó la urgencia inicial y solo una pequeña proporción se relaciona con errores en el diagnóstico o tratamiento de la urgencia previa.