Factors associated with recurrent emergency department visits among people living with dementia: A retrospective cohort study

Abstract

BackgroundResearch on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits.MethodsWe used health administrative databases to conduct a population‐based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community‐dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk.ResultsOur cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low‐income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines.ConclusionsHistory of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia‐friendly and geriatric‐focused EDs. Collaborative medication review in the ED and closer follow‐up and engagement with community supports could improve patient care and experience.

Patient‐reported outcome measure use among older adults after emergency department care: A systematic review

“…Historically, post‐ED outcome assessments have relied on health care utilization evaluation (e.g., repeat ED visit, hospitalization) with little focus on outcomes preferred by older adults 10–12 . Patient‐reported outcome measures (PROMs) have increased in use recently, as they offer an opportunity to capture patients’ health‐related quality of life (QoL), condition‐specific symptom burden, functional disability, and other health‐related considerations 13–15 .…”

Recurrent emergency department visits among persons living with dementia: Bending the curve

“…As identified by Jones and colleagues in this issue of the Journal of the American Geriatric Society, one opportunity to improve care relates to reducing emergency department (ED) revisits among this vulnerable population. 1 The study used Ontario provincial administrative data to measure the incidence of ED revisits within 1 year (62% experienced at least one revisit) among older PLWD. Although important clinical and social data (e.g., severity of dementia, functional status, social supports) were unavailable for the analyses and only proxy measures were available for some characteristics (e.g., income and rurality for access to care), Jones and colleagues identified important factors associated with revisits (previous ED use, comorbidities, medications, and patient characteristics).…”

“…Although important clinical and social data (e.g., severity of dementia, functional status, social supports) were unavailable for the analyses and only proxy measures were available for some characteristics (e.g., income and rurality for access to care), Jones and colleagues identified important factors associated with revisits (previous ED use, comorbidities, medications, and patient characteristics). 1 The study's use of ED revisit within 1 year, instead of a shorter window such as 14 or 30 days, as the outcome measure does result in heterogeneity in the reason for revisiting the ED. Some of the reasons for ED revisits will be related to the initial ED visit, while others will result from chronic medical and social issues, a pattern they identified and published previously.…”

“…Geriatric EDs, as noted by Jones and colleagues, also present a valuable resource to improve care for PLWD. 1 To be a certified geriatric ED, the facility and attached hospital must meet numerous structural and process standards to deliver optimal care to older adults. One set of standards adds clinicians with geriatric emergency medicine expertise to provide education for all clinicians to enhance their knowledge and skills.…”