Prompt Outpatient Care For Older Adults Discharged From The Emergency Department Reduces Recidivism.

Phillip D Magidson,Orla C Sheehan,David L Roth,Jin Huang,Emily B Levitan,Andrew O Westfall

doi:10.5811/westjem.2020.8.47276

Abstract

IntroductionOlder adults present unique challenges to both emergency clinicians and health systems. These challenges are especially evident with respect to discharge after an emergency department (ED) visit as older adults are at risk for short-term, negative outcomes including repeat ED visits. The aim of this study was to evaluate characteristics and risk factors associated with repeat ED utilization by older adults.MethodsED visits among participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study between 2003–2016 were examined using linked Medicare claims data to identify such visits and resulting disposition. Multilevel proportional hazards models examined associations of age, comorbidity status, race, gender, Medicaid dual eligibility status, social support characteristics (living alone or caregiver support), and use of ambulatory primary and subspecialty care with repeat ED utilization.ResultsOlder adults discharged from the ED seen by a primary care provider (hazard ratio [HR] = 0.93, confidence interval [CI], 0.87–0.98, p = 0.01) or subspecialist (HR = 0.91, CI 0.86–0.97, P <0.01) after the ED visit were less likely to return to the ED within 30 days compared to those who did not have such post-ED ambulatory visits. Additionally, comorbidity (HR =1.14, 95% CI, 1.13–1.16, P <0.01) and dual eligibility for Medicare and Medicaid (HR = 1.34, 95% CI, 1.20–1.50, p<0.01) were associated with return to the ED within 30 days. Those who were older (HR = 1.10, 95% CI, 1.05–1.15), had more comorbidities (HR = 1.17, 95% CI 1.15–1.18), Black (HR = 1.23, 95% CI, 1.14–1.33,P <0.01), and dually eligible (HR =1.23, 95% CI, 1.14–1.33, P <0.01) were more likely to return within 31–90 days after their initial presentation. The association of outpatient visits with repeat ED visits was no longer seen beyond 30 days. Patients without a caregiver or who lived alone were no more likely to return to the ED in the time periods evaluated in our study.ConclusionBoth primary care and subspecialty care visits among older adults who are seen in the ED and discharged are associated with less frequent repeat ED visits within 30 days.

Highlights

Older adults present unique challenges to both emergency clinicians and health systems
Older adults discharged from the emergency department (ED) seen by a primary care provider or subspecialist (HR = 0.91, CI 0.86-0.97, P
The association of outpatient visits with repeat ED visits was no longer seen beyond 30 days

Summary

Introduction

Older adults present unique challenges to both emergency clinicians and health systems. Geriatric patients use the ED at disproportionally higher rates.[1,2,3] Older patients seen in the ED are more likely to have extended lengths of stay, higher resource utilizations during their stays, and are more than three times as likely to be admitted to the hospital and five times more likely to be admitted to the intensive care unit, compared to younger patients.[2,3,4,5,6] The increased cost of acute care services is one of the highest drivers of Medicare spending Shifting this expensive, inpatient care to the post-acute and outpatient setting is one way to reduce healthcare spending; discharging older patients after an ED visit is not without risk. Despite many emergency clinicians working to establish outpatient appointments prior to discharge, some smaller, single-center studies suggest outpatient follow-up after ED discharge may not reduce future ED utilization and repeat visits.[10,11]

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