Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department

Abstract

ImportanceThe role of patient-level factors that are unrelated to the specific clinical condition leading to an emergency department (ED) visit, such as functional status, cognitive status, social supports, and geriatric syndromes, in admission decisions is not well understood, partly because these data are not available in administrative databases.ObjectiveTo determine the extent to which patient-level factors are associated with rates of hospital admission from the ED.Design, Setting, and ParticipantsThis cohort study analyzed survey data collected from participants (or their proxies, such as family members) enrolled in the Health and Retirement Study (HRS) from January 1, 2000, to December 31, 2018. These HRS data were linked to Medicare fee-for-service claims data from January 1, 1999, to December 31, 2018. Information on functional status, cognitive status, social supports, and geriatric syndromes was obtained from the HRS data, whereas ED visits, subsequent hospital admission or ED discharge, and other claims-derived comorbidities and sociodemographic characteristics were obtained from Medicare data. Data were analyzed from September 2021 to April 2023.Main Outcomes and MeasuresThe primary outcome measure was hospital admission after an ED visit. A baseline logistic regression model was estimated, with a binary indicator of admission as the dependent variable of interest. For each primary variable of interest derived from the HRS data, the model was reestimated, including the HRS variable of interest as an independent variable. For each of these models, the odds ratio (OR) and average marginal effect (AME) of changing the value of the variable of interest were calculated.ResultsA total of 42 392 ED visits by 11 783 unique patients were included. At the time of the ED visit, patients had a mean (SD) age of 77.4 (9.6) years, and visits were predominantly for female (25 719 visits [60.7%]) and White (32 148 visits [75.8%]) individuals. The overall percentage of patients admitted was 42.5%. After controlling for ED diagnosis and demographic characteristics, functional status, cognition status, and social supports all were associated with the likelihood of admission. For instance, difficulty performing 5 activities of daily living was associated with an 8.5–percentage point (OR, 1.47; 95% CI, 1.29-1.66) AME increase in the likelihood of admission. Having dementia was associated with an AME increase in the likelihood of admission of 4.6 percentage points (OR, 1.23; 95% CI, 1.14-1.33). Living with a spouse was associated with an AME decrease in the likelihood of admission of 3.9 percentage points (OR, 0.84; 95% CI, 0.79-0.89), and having children living within 10 miles was associated with an AME decrease in the likelihood of admission of 5.0 percentage points (OR, 0.80; 95% CI, 0.71-0.89). Other common geriatric syndromes, including trouble falling asleep, waking early, trouble with vision, glaucoma or cataract, use of hearing aids or trouble with hearing, falls in past 2 years, incontinence, depression, and polypharmacy, were not meaningfully associated with the likelihood of admission.Conclusion and RelevanceResults of this cohort study suggest that the key patient-level characteristics, including social supports, cognitive status, and functional status, were associated with the decision to admit older patients to the hospital from the ED. These factors are critical to consider when devising strategies to reduce low-value admissions among older adult patients from the ED.

Trends in observation stays for Medicare beneficiaries with and without Alzheimer's disease and related dementias

“…However, any efforts to further drive down admission rates for the AD/ADRD population must consider factors that are not traditionally available in claims data (e.g., social supports, functional status). 40 While it is reassuring that outcomes have improved in recent years for emergency care for Medicare beneficiaries overall 41 and with AD/ADRD, 42 evidence specifically examining the impact of the apparent substitution of observation stays for inpatient care is needed in the AD/ADRD population. Our findings are also consistent with other work suggesting that community-dwelling people with AD/ADRD are a distinct population with high rates of acute care utilization that differ from those in long-term care settings.…”

Considering the Whole Person in Hospital Admission Decisions for Older Adults in the Emergency Department

“…For some conditions, risk scores allow clinicians to identify patients with sufficiently low risk for adverse events who may be amenable to discharge rather than hospitalization. However, risk scores have not traditionally incorporated the types of variables that were examined in the study by Smulowitz et al 1 Their findings suggest that these factors were perceived by clinicians to be associated with patient outcomes and therefore to be relevant to decision-making. The absence of these factors in clinical risk scores may then explain why patients with low risk continue to be hospitalized.…”

Older patients referred for geriatric consultation in the emergency department: characteristics and healthcare utilization

“…Indeed, to our knowledge, studies that investigated patients’ characteristics associated with referral for a geriatric consultation in the ED are scarce [ 27 ]. Uncertainty remains regarding how best to identify older patients at increased risk of complex health care trajectories, including 30-day hospital readmission [ 23 , 28 – 31 ], even though recent studies highlight the importance of functional, cognitive, as well as social status as major determinants of older ED patients’ risk to be admitted to the hospital [ 32 ].…”