Recording early deaths following emergency department visits in inpatient data: An observational study using data of 16 German hospitals

Objective: In German hospital emergency departments (EDs), no definite reimbursement rules exist for patients who die within 24 hours after arrival. Our study aimed to assess whether these cases were recorded and billed as inpatient stays. Furthermore, characteristics of patients who die within 24 hours following arrival at the ED were investigated for all ED visits, as well as for the subgroup of ED visits with an ED diagnosis or inpatient principal diagnosis of acute myocardial infarction.Methods: This study was part of the INDEED project, which aimed to explore utilization and transsectoral patterns of care for patients treated in EDs in Germany. The study population includes ED visits of adult patients in 2016 in 16 German hospitals participating in the project. In the data set of combined ED, inpatient, and outpatient treatment information early deaths were classified as patients who died in the ED or in the hospital within 24 hours after arrival. Characteristics of visits followed by early death were analyzed descriptively. Mode of billing as inpatient or outpatient was validated by identifying corresponding billing information using linked inpatient and outpatient data.Results: In 2016, 454,747 ED visits of adult patients occurred in the participating hospitals and 42.8% resulted in inpatient admission. Among these inpatients 8,317 (4.3%) died during the overall hospital stay, and 1,302 (0.7%) died within 24 hours following arrival. The proportion of early deaths among all deaths in patients with a diagnosis of acute myocardial infarction was higher (27%) compared to the overall patient population (16%). Although all cases of early death were classified as inpatients the corresponding inpatient data was missing in 1.9% of all early deaths and in 3.4% of early deaths with a diagnosis of acute myocardial infarction. Outpatient billing information suggesting that these cases were billed as outpatients, was found in 0.3% of all early deaths and in 0.8 to 1.7% of early deaths with a diagnosis of acute myocardial infarction, respectively. Conclusion: In-hospital mortality might be biased by incomplete recording of early deaths in inpatient data. However, the proportion of patients with early death who were billed as outpatients was marginal in the investigated study population of 16 hospitals. Although the study results are limited by restricted generalizability and subpar data quality, this finding indicates that early deaths might be almost completely recorded in German inpatient data. Nevertheless, data quality should be enhanced by establishing general billing rules for cases with a short treatment duration due to early death.