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Is less more, or is it less? The growing evidence on high-intensity hospital care
  1. Ziad Obermeyer1,2
  1. 1Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  2. 2Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
  1. Correspondence to Dr Ziad Obermeyer, Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St, Neville House, Boston, MA 02115, USA; zobermeyer{at}bwh.harvard.edu

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The evidence seems clear: we spend so much on healthcare, and get so little in return. Despite wide variation in the amount we spend on care, patients’ outcomes are often the same.1 So clearly, we should just do less. Indeed, given the growing problems of overdiagnosis and overtreatment, less is more.

As emergency physicians, we deliver a fair amount of high-intensity care. Yes, good care can sometimes be as simple as an astute diagnosis or a kind word. But it can also involve cross-sectional imaging, invasive procedures and hospital admission. At the right time and for the right patient, we believe, this care can be the difference between life and death.

And yet this care is coming under increasing scrutiny from payers and policy makers.

While emergency care accounts for a small fraction of direct health system costs,2 the decision to admit a patient to the hospital is an expensive one indeed. There are many good reasons to send patients home—reducing crowding, avoiding hospital-acquired infections and more. But the driving force behind efforts to reduce admissions today is simple: to reduce costs. As a result, physicians everywhere face increasing pressure to discharge patients to home.

This poses a particular dilemma for emergency physicians. On one hand, the rest of the world seems very certain we should be sending more patients home. On the other, our experience suggests that failures of risk stratification and mistriage to home can have terrible consequences.

So where is the evidence?

Early death after discharge from the ED

Recently my colleagues and I published a study investigating how often generally healthy people sent home from US EDs died in the week after discharge.3 Two of our key findings are relevant to current debates about the value of hospital care.

First, death in the week after discharge happens more often than we thought, about 10 000 times per …

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