Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns.
BACKGROUND
It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates.


METHODS
Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen's behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects.


RESULTS
We identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58).


CONCLUSIONS
We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.
Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA. Brian-Kaskie@uiowa.edu.
Brian
B
Kaskie
Maksym
M
Obrizan
Michael P
MP
Jones
Suzanne
S
Bentler
Paula
P
Weigel
Jason
J
Hockenberry
Robert B
RB
Wallace
Robert L
RL
Ohsfeldt
Gary E
GE
Rosenthal
Fredric D
FD
Wolinsky
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D004630:Emergencies / Q000453:epidemiology / Q000523:psychology*; D004632:Emergency Medical Services / Q000639:trends*; D004636:Emergency Service, Hospital / Q000639:trends*; D005260:Female; D006801:Humans; D008297:Male; D011446:Prospective Studies; D012720:Severity of Illness Index