Emergency department reorganisation introducing increased autonomy: A mixed effects approach to evaluate the effects of a national policy.

Abstract

BackgroundIn 2007, a Danish national policy to future-proof emergency department (ED) performance was launched. The policy included several recommendations for the management and organisation of care that essentially introduced greater ED autonomy. In this study, we evaluate the effects of increased ED autonomy on readmission, mortality and episode costs for two large patient groups.MethodA non-randomised stepped wedge study-design where all EDs gradually implemented the policy at different steps during the study period (2008-2016). The timing and extent of policy implementation was determined from a retrospective cross-sectional survey of all 21 Danish EDs. This was linked to all episodes of hip fracture (n = 79,697) and erysipelas (n = 39,900) identified in the Nation Patient Registry and with episode-level outcomes. Mixed effect models were specified for the outcomes of 30-day readmission, 30-day mortality and episode costs, and adjusted for relevant ED- and episode-level heterogeneity.ResultsIncreased ED autonomy was associated with more readmissions (pConclusionThe intended policy effects were not found for these two patient groups; in fact, reorganisation appeared to have harmed hip fracture patients and increased episode costs. Uncertainty remains regarding the longer-term consequences.