Huge Increase in Emergency Room Visits Due to Atrial Fibrillation

Researchers have reported a sharp increase in emergency room visits and hospitalizations triggered by atrial fibrillation (AF).

The study team, which presented its findings at the Scientific Sessions of the 2014 Meeting of the American Heart Association, pulled data about emergency department usage nationally and analyzed information about patients who received a primary diagnosis of AF between 2006 and 2011.

The rate of emergency department visits increased steadily, rising from 133 visits per 100,000 people in the first year to 165 visits per 100,000 people in the last — a 24% jump.

Overall, the researchers found that patient care improved over the study period. In-hospital death rates fell from 1.18% in 2006 to 0.97% in 2011.

The research team also found that hospital admission rates rose during the study period, from 62.5% in 2006 to 67% in 2011. In all, emergency room doctors admitted more than 2.7 million patients over the study period, but they did not admit all patient groups in equal percentages.

Doctors were more likely to admit patients who were elderly, female, insured by Medicare or Medicaid, living in areas with low median income, living in the northeast or living in large metropolitan areas. Doctors at teaching hospitals, moreover, were more likely to admit patients than doctors at other facilities.

The study team’s analysis concluded that doctors, in many cases, were admitting too many patients and creating costs the system could not continue to bear as the number of people with AF continues to rise.

“The huge demographic and geographic variations highlight the unmet need for interventions to decrease hospitalization rates,” said lead researcher SourabhAggarwal, MD, Chief Resident in the Department of Internal Medicine at Western Michigan University School of Medicine.

Several other recent papers have studied the cost of admitting so many patients with AF and considered ideas for identifying patients who can safely be sent home.

Researchers from Vanderbilt University, for example, developed and validated a protocol they call the Risk Estimator Decision Aid for Atrial Fibrillation (RED-AF).

Their tool is a formula that produces a single risk score from information about 12 risk factors: age, sex, hypertension, smoking, inadequate 2-hour emergency department ventricular rate control, dyspnea, ongoing beta-blocker use, ongoing diuretic use, heart failure, peripheral edema, chronic obstructive pulmonary disease, and heart palpitations in the emergency department.

The RED-AF performed better (retrospectively) than standard emergency room procedure in determining which patients should have been sent home during the ongoing Atrial Fibrillation and Flutter Outcome Risk Determination trial.

There is, however, plenty of room for improvement. The validation analysis found that RED-AF exhibited a sensitivity of 0.96, a specificity of 0.19, a positive predictive value of 0.27, and a negative predictive value of 0.93.

There is also plenty of incentive to develop improved protocols for determining which patients get hospitalized and which get sent home from the emergency department.

The hospitalization of AF patients costs billions of dollars per year, but the analysis by Aggarwal’s team found that the most hospitalized groups enjoyed no benefits over the least hospitalized groups. Indeed, the 30-day risk of stroke for patients who come to the emergency room with AF is just 1% to 3% — far too little to justify a hospitalizing the vast majority of patients.