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Open Access Research article

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns

Brian Kaskie1*, Maksym Obrizan2, Michael P Jones3, Suzanne Bentler1, Paula Weigel1, Jason Hockenberry45, Robert B Wallace6, Robert L Ohsfeldt7, Gary E Rosenthal8 and Fredric D Wolinsky9

Author Affiliations

1 Department of Health Management and Policy, College of Public Health, the University of Iowa, Iowa City, Iowa, USA

2 Kyiv School of Economics, and Kyiv Economics Institute, Kyiv, Ukraine

3 Department of Biostatistics, College of Public Health, the University of Iowa, Iowa City, Iowa; and Comprehensive Access and Delivery Evaluation and Research (CADRE) Center, Iowa City Veterans Administration Medical Center, Iowa City, USA

4 Comprehensive Access and Delivery Evaluation and Research (CADRE) Center, Department of Health Management and Policy, College of Public Health, the University of Iowa, Iowa City, Iowa and National Bureau of Economic Research, USA

5 Department of Health Management and Policy, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA

6 Department of Epidemiology, College of Public Health, the University of Iowa, Iowa City, Iowa, USA

7 Department of Health Management and Policy, School of Rural Public Health, Texas A&M University Health Science Center, College Station, Texas, USA

8 Department of Internal Medicine, Carver College of Medicine, the University of Iowa, Iowa City, Iowa, USA

9 Department of Health Management and Policy, College of Public Health, the University of Iowa, Iowa City, Iowa; Department of Internal Medicine, Carver College of Medicine, the University of Iowa, Iowa City, Iowa; Department of Adult Nursing, College of Nursing, the University of Iowa, Iowa City, Iowa, USA

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BMC Geriatrics 2011, 11:65  doi:10.1186/1471-2318-11-65

Published: 21 October 2011

Abstract

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.