Measuring Safe Discharge Rates for Adults with Low-Risk Chest Pain: MVC Estimated $19M in Averted Costs at MEDIC Emergency Departments
“Chest pain is a common reason people visit the emergency department. Thanks to the collaborative partnerships within MEDIC, more low-risk patients can safely recover at home—making their experience better and helping Michigan’s health care system avoid an estimated $19 million in unnecessary hospitalizations from 2021 to 2024.” Keith Kocher, MD, MPH, MEDIC Medical Director
Background
The Michigan Emergency Department Improvement Collaborative (MEDIC) is a Collaborative Quality Initiative (CQI) that aims to improve care and outcomes in Michigan emergency rooms by sharing best practices, providing quality improvement (QI) resources, and creating data-driven reports. One of MEDIC’s initiatives focuses on reducing unnecessary hospital admissions among adults who present with chest pain but have low risk of a major cardiac adverse event. Experiencing chest pain can be alarming to patients and ties to numerous diagnoses, ranging widely in severity, type, and urgency of treatment. While severe cases may require an immediate intervention and admission to the hospital, many cases can be identified using evidence-based guidelines as low risk and managed in the emergency department (ED) before being safely discharged home.
MEDIC’s Safe Discharge for Adults with Low Risk Chest Pain Initiative aims to ensure patients presenting with chest pain to the ED are evaluated consistent with evidence-based guidelines to ensure exclusion of harmful conditions, including acute coronary syndrome, before being safely discharged home. Safe discharge is defined as discharge from the ED without an inpatient admission or observation stay on the day of their visit and without returning to the ED or requiring admission within seven days after discharge. Patients who are safely discharged may receive outpatient follow-up care for further evaluation and treatment. By minimizing avoidable hospital admissions, this initiative seeks to improve patient care and outcomes while reducing healthcare spending and utilization. To support this work, MEDIC developed a toolkit, provider reference card, and other resources for providers in Michigan EDs.
To help evaluate the impact of this work on healthcare utilization, MEDIC reached out to the Michigan Value Collaborative (MVC) to leverage its robust claims-based data. Together, MVC and MEDIC quantified cost savings from the reduction of same-day inpatient admissions among MEDIC-participating hospitals using MVC’s ED-based episodes of care. This evaluation calculates the safe discharge rate (i.e., patients discharged from the ED without an inpatient admission or observation stay and no subsequent ED visit or admission within seven days of discharge) at the start of and throughout the initiative’s implementation for participating hospitals. The change in safe discharge rate was used to estimate savings from reduced avoidable admissions and observations stays in MEDIC EDs.
Methodology
MVC and MEDIC defined the cohort as patients age 18 or older who visited the ED and were covered by Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, BCBSM PPO Medicare Advantage (MA), Blue Care Network (BCN) HMO Commercial, BCN HMO MA, Michigan Medicaid, or Medicare Fee-For-Service (FFS). The date range for ED visits included in the analysis was 01/01/2020-11/30/2024 for all BCBSM/BCN plans and Medicaid, and 01/01/2020-05/31/2024 for Medicare FFS. This analysis used 30-day ED-based episodes of care for chest pain to determine the rate of safe discharge within the treatment period of 2021-2024 at MEDIC-participating hospitals. Episodes were excluded if the patient died during the index event or left against medical advice, and episodes from Critical Access Hospitals were also excluded. Rates of safe discharge at the start of and throughout the initiative’s implementation period were used to estimate the number of events averted. MVC’s price-standardized, risk-adjusted (i.e., age, sex, payer, hierarchical condition categories, and high prior spending) payment data was then used to estimate cost savings from averted events.
Limitations
The analysis required a defined cohort of MEDIC participating hospitals, which was achieved by coding each hospital as participating or not for the time period. However, some hospitals may have participated in MEDIC or the initiative at different points in the implementation period. Payment averages were calculated using payments price standardized to the Medicare FFS schedule, which may underestimate total cost savings.
Findings
MVC observed a statistically significant increase in safe discharge rates over time across MEDIC-participating hospitals (Figure 1) between 2020 and 2024. When adjusting for differences based on gender, payer, age, comorbidities, hospital, hierarchical condition categories, and high 180-day prior spending, the odds of safe discharge were 65% higher in 2024 than in 2020 among MEDIC sites (p<0.0001). MVC estimated there were 5,441 same-day inpatient admissions or observation stays averted during the treatment period among MEDIC-participating hospitals, based on the higher average rate of safe discharge during the treatment period relative to the baseline year (Table 1). The average price-standardized, risk-adjusted total episode payment among patients who had a safe discharge was $2,308, whereas the average price-standardized, risk-adjusted total episode payment among patients with an inpatient admission, observation stay, or return to the ED or hospital within seven days of index discharge was $5,829. This represents a price-standardized cost difference of $3,521. Therefore, the total direct cost savings from increased rates of safe discharge in 2021 through 2024 were estimated to be $19,156,742. This demonstrated that MEDIC sites delivered significant net savings for its patients, BCBSM, and hospitals in MI.
Figure 1. Risk-Adjusted Safe Discharge Rates for Patients Ages 18+ with Chest Pain Treated in MEDIC-Participating EDs, 2020-2024
Adjusted Odds Ratio: 1.65, p<0.0001
Table 1. Safe Discharge Metrics for MEDIC-Participating EDs, 2020-2024
