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.