Hospital-Level Variation and Predictors of Admission after Emergency Department Visits for Atrial Fibrillation: 2006–2011

Abstract Background Outpatient management of atrial fibrillation can be a safe alternative to inpatient admission after emergency department (ED) visits. We aim to describe trends and predictors of hospital admission for atrial fibrillation and determine the variation in admission among U.S. hospitals. Methods We analyzed ED visits and hospital admissions for adult patients with a principal diagnosis of atrial fibrillation or atrial flutter in the Nationwide Emergency Department Sample 2006–2011. We identified patient and hospital characteristics associated with admission using hierarchical multivariate logistic regression. We analyzed admission rates overall and for patients at low risk of thromboembolic complications (CHA2 DS2 -VASc score zero). We compared hospital-level variance to residual variance to estimate the intra-class correlation (ICC) in models with and without hospital characteristics. Results From 2006–2011 annual ED visits for atrial fibrillation and atrial flutter increased by 30.9%; admission rates decreased from 69.7% to 67.4% (P = .02). Admission was associated with setting (metropolitan teaching vs. Non-metropolitan, OR = 1.93 [1.62, 2.29]) and region (Northeast vs. West, OR = 2.09 [1.67, 2.60]). Among patients with zero CHA2 DS2 -VASc score, the national average admission rate was 46.4%. The ICC was 20.7% adjusting for patient characteristics and hospital clustering; and 19.2% after additionally adjusting for hospital variables. Conclusions From 2006 to 2011 ED visits for atrial fibrillation in the U.S. increased by almost a third, with a minimal change in ED admission rates. One-fifth of variation in admission rates is due to hospital site and not explained by hospital characteristics. Hospital-specific practice patterns may identify opportunities to increase outpatient management.