Article
Emergency Department Visits and Resulting Hospitalizations by Elderly Nursing Home Residents, 2001–2008
Research on Aging 2014, Vol. 36(2) 207-227 ª The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0164027512473488 roa.sagepub.com
Chun-Ju Hsiao1 and Esther Hing1
Abstract This study examines emergency department (ED) visits by nursing home (NH) residents aged 65 and over, and factors associated with hospital admission from the ED visit using data from the 2001–2008 National Hospital Ambulatory Medical Care Survey. Cross-sectional analyses were conducted on patient characteristics, diagnosis, procedures received, and triage status. On average, elderly NH residents visited EDs at a rate of 123 visits per 100 institutionalized persons. Nearly 15% of all ED visits had ambulatory care sensitive condition diagnoses. Nearly half of these visits resulted in hospital admission; chronic obstructive pulmonary disease, congestive heart failure, kidney/urinary tract infection, and dehydration were associated with higher odds of admission. Previous studies suggested that adequate medical staffing and appropriate care in the NH could reduce ED visits and hospital admissions. Recent initiatives seek to reduce ED visits and hospitalizations by providing financial incentives to spur better coordination between NH and hospital.
1
National Center for Health Statistics, Hyattsville, MD, USA
Corresponding Author: Chun-Ju Hsiao, National Center for Health Statistics, 3311 Toledo Road, Hyattsville, MD 20782, USA. Email: [email protected]
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Research on Aging 36(2)
Keywords ambulatory care sensitive conditions, hospital admissions, long-term care
Emergency departments (EDs) are used by nursing home (NH) residents at rates almost 5 times higher at ages 65–74 and almost 3 times higher at ages 75 and older than their noninstitutionalized counterparts (McCaig & Burt, 2005). Almost half of ED visits made by NH residents resulted in hospitalizations (Wang, Shah, Allman, & Kilgore, 2011). Further research is needed to characterize whether ED visits by this population, particularly those eventually hospitalized, can be reduced or avoided. This study uses nationally representative data to examine characteristics of ED visits made by elderly NH residents as well as factors associated with hospital admission from the ED. This study specifically focuses on the relationship of ED visits and subsequent inpatient hospitalization with ambulatory care sensitive conditions (ACSCs).
Description of the Problem Prior research found that NH residents present at EDs with greater medical acuity and complexity than their noninstitutionalized counterparts (Wang et al., 2011). When NH residents are transferred to EDs, their care is often fragmented with little continuity of care between the NH and hospital (Ackermann, Kemle, Vogel, & Griffin, 1998). Information critical to effective emergency care such as the mental status and medical conditions of NH residents is often not available to ED staff (Ackermann et al., 1998; Zimmer, Eggert, Treat, & Brodows, 1988). In addition, obtaining a complete and accurate medical history is often difficult for ED staff when cognitive problems exist among these patients (Vladeck, Miller, & Clauser, 1993). Thus, lack of information and the frail health of these patients pose challenges to the hospital and ED staff. If the ED visit results in admission to the hospital, the stay itself may be hazardous for the elderly NH resident. Studies have reported that the elderly commonly experience functional decline, delirium, iatrogenic illnesses, and other adverse events during hospital stays (Covinsky et al., 2003; Creditor, 1993; Ebersole & Hess, 2001; Inouye et al., 1999). In addition, there are cost and efficiency concerns associated with hospitalization of NH residents. A study showed that the average spending for NH resident’s hospitalization with any ACSC was $10,140. Among ACSC hospitalizations, asthma, pneumonia, and diabetes
Downloaded from roa.sagepub.com at UNIV OF CONNECTICUT on June 17, 2015
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were the most costly conditions (Grabowski, O’Malley, & Barhydt, 2007). The average cost of ED visits for people age 65 and up was $1,306 (Agency for Healthcare Research and Quality, 2009). The cost for ED visits could be higher for NH residents because of their greater medical acuity and complexity. Due to the problems that NH residents encounter in the ED, some researchers have examined the extent of unnecessary ED visits and hospital admissions from EDs among the NH population (Irvine, Van Buren, & Crossley, 1984; Kerr & Byrd, 1991; Stark, Gutman, & McCashin, 1982). However, most of the data are outdated or derives from a single ED or NH. One study used 2004 national data to examine potential preventable ED visits by NH residents, but it used reason for visit, instead of the actual diagnosis to classify potentially preventable ED visits (Caffrey, 2010). In addition, the study did not have information on ED visits, nor whether such visits resulted in a subsequent inpatient admission or not. The Institute of Medicine (IOM) has recommended use of hospitalizations for ACSCs as an indicator for whether appropriate care was provided to avoid hospitalization (Institute of Medicine [IOM], 1993). The IOM’s ACSCs indicator has been used increasingly to examine the appropriateness of ED visits by NH residents and subsequent hospitalizations (Carter, 2003; Carter, Datti, & Winters, 2006; Carter & Porell, 2005; Grabowski et al., 2007; Intrator, Castle, & Mor, 1999; Intrator, Zinn, & Mor, 2004). A study used 2000–2002 National Hospital Ambulatory Care Survey (NHAMCS) data to compare ACSCs among ED visits made by older adults inside and outside of NHs. The study found higher risk for ACSCs and hospitalizations for NH residents compared with their noninstitutionalized counterparts (Carter et al., 2006). A more recent study used 2005–2008 NHAMCS data to characterize ED use by NH residents, but it did not examine characteristics associated with hospital admissions from EDs (Wang et al., 2011).
Purpose We use national data from 2001 to 2008 to examine ED use and subsequent hospital admission among NH residents. The large sample size permits more detailed analyses with two specific aims: (1) evaluate and characterize ED visits made by NH residents, including whether the ED visit resulted in hospital admission: and (2) examine whether presence of ACSCs was associated with hospitalization from the ED.
Downloaded from roa.sagepub.com at UNIV OF CONNECTICUT on June 17, 2015
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Method Data Source The study is based on nationally representative samples of ED visits collected in the 2001–2008 NHAMCS. The scope of NHAMCS is patient visits to EDs and outpatient departments of non-Federal, short stay, or general hospitals. For the purpose of this study, we only use data from the ED component of the NHAMCS. NHAMCS employs a four-stage probability sample design involving samples of geographic primary sampling units (PSUs), hospitals with EDs within PSUs, emergency service areas (ESAs) within EDs, and patient visits within ESAs. The final sampling stage involves a systematic random sample of ED visits during a randomly assigned 4-week reporting period. The U.S. Census Bureau, acting as the data collection agency for the survey, provided training to field representatives throughout the nation who, in turn, oversaw data collection at the hospital. Hospital staff were instructed to complete the information requested on the patient record form. During 2001–2008, data were collected for 287,803 sampled ED visits from non-Federal, short stay, and general hospitals. During this time period, the average number of participating hospital EDs was 367. The unweighted response rate for each year ranged from 85.3 to 91.9% (McCaig & Burt, 2003, 2004, 2005; McCaig & Nawar, 2006; National Center for Health Statistics [NCHS], 2010; Nawar, Niska, & Xu, 2007; Niska, Bhuiya, & Xu, 2010; Pitts, Niska, Xu, & Burt, 2008).
Measurement The information regarding patient residence on the patient record form was collected in two different manners across the years. From 2001 to 2004, NH residents were identified by the question ‘‘Does the patient reside in a NH or other institution?’’ From 2005 to 2008, the NH residence was among several response choices for patient residence. Although it is possible that some ED visits with positive responses to the question in 2001–2004 may have been in an institution other than a NH (e.g., prison, mental hospital), we limited this possibility by focusing our analysis exclusively on ED visits among the elderly (i.e., those aged 65 or older). We also compared 2001–2004 estimates with 2005–2008 combined estimates for potential differences due to question wording and found no statistical differences in estimates. In our analysis, ED visits among patients whose place of residence was marked as unknown were assumed to reside in the community based on the similarity of characteristics for these cases with those responding ‘‘No’’ in 2001–2004 or ‘‘private
Downloaded from roa.sagepub.com at UNIV OF CONNECTICUT on June 17, 2015
Hsiao and Hing
211
residence’’ in 2005–2008. Basic characteristics of ED visits in 2001–2004 versus 2005–2008 were generally very similar (data not shown).
Statistical Analysis We conducted two types of analyses in the study. The descriptive analysis characterizes ED visits by NH residents and the second analysis models the likelihood of hospitalization among NH residents’ ED visits. The descriptive analysis includes the average annual ED visit rates among elderly NH residents per 100 institutionalized persons during 2001–2008. ED visit rates were calculated by dividing the estimated count of ED visits among the elderly NH residents by estimates of the civilian institutionalized population in each cohort of interest for the same years, overall, by age (65–74, 75–84, 85þ), sex, and race (White, non-White). For example, the visit rate for males was obtained by taking the weighted ED visits made by males divided by the male institutionalized population estimated by the Census Bureau. The institutionalized population estimates were derived by subtracting estimates of the civilian noninstitutionalized population from estimates of the civilian resident population as of each year during 2001–2008. Each set of annual population estimates are projections based on Census 2000 data developed by the Population Division, U.S. Census Bureau using the July 1 set of state population estimates (U.S. Census Bureau). The descriptive analysis also summarizes the services ordered or provided during ED visits and outcomes of ED visits by elderly NH residents. We calculated the mean number of diagnostic or screening tests performed based on responses to a number of check boxes (ranging from 21 to 30 during 2001–2008) indicating whether any of the specific diagnostic or screening tests were ordered or performed. We also calculated the percent of ED visits among elderly NH visits that had each of the nine most frequent diagnostic or screening tests performed. In addition, we estimated the mean number and the percent of the five most frequent procedures performed from a list of possible procedures indicated (11 procedures for 2001–2006 and 13 procedures for 2007–2008). We also summarized information on triage status (nonurgent, semiurgent, urgent, emergent, or unknown/no triage), and disposition status (no follow-up planned, return if needed, return/refer to other physician or clinic, transfer to other facility, or admit to hospital). Finally, we compared the mean number of diagnostic tests and procedures as well as the percentage of subsequent hospitalization between ED visits with and without ACSCs. To examine the relationship between ACSCs and hospitalization following ED visits, a multivariate logistic regression model was performed. The
Downloaded from roa.sagepub.com at UNIV OF CONNECTICUT on June 17, 2015
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dependent variable for the model was whether the visit resulted in admission to the hospital. Patients who were dead on arrival or died in ED were excluded from the logistic regression. The main independent variable was the presence of ACSCs. Presence of ACSCs was determined by the first-listed diagnosis as coded by the International Classification of Diseases, 9th Revision, Clinical Modification codes as developed by Millman et al (IOM, 1993). The first-listed diagnosis is the diagnosis to which the ED visit has been attributed. The list of 13 ACSCs included grand mal seizure disorders, severe ear, nose, and throat infections, chronic obstructive pulmonary disease (COPD), bacterial pneumonia, asthma, congestive heart failure (CHF), hypertension, angina, cellulitis, diabetes, hypoglycemia, kidney/urinary tract infection, and dehydration. In the multivariate model, we also controlled for several possible confounders based on the Andersen model of health services use (Aday & Andersen, 1974). The predisposing components include variables that describe individuals’ tendency to use services. The enabling components represent the means that are available to individuals for the use of services, including both resources to the individual and family as well as attributes of the community. The need components refer to illness level. The need components are hypothesized to be the most immediate determinants of health service use while the predisposing components are the most distant determinants. In this article, predisposing factors included age (65–74 years, 75–84 years, 85 years, and over), sex, race (White, non-White). Enabling factors included expected payment source (private insurance, Medicare, Medicaid, other) and metropolitan statistical area (MSA) status (yes, no). In addition to ACSCs, need factors included number of procedures (0–1, 2, or more), number of ED diagnoses (0–1, 2, or 3), and triage information (
Emergency Department Visits and Resulting Hospitalizations by Elderly Nursing Home Residents, 2001–2008
Research on Aging 2014, Vol. 36(2) 207-227 ª The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0164027512473488 roa.sagepub.com
Chun-Ju Hsiao1 and Esther Hing1
Abstract This study examines emergency department (ED) visits by nursing home (NH) residents aged 65 and over, and factors associated with hospital admission from the ED visit using data from the 2001–2008 National Hospital Ambulatory Medical Care Survey. Cross-sectional analyses were conducted on patient characteristics, diagnosis, procedures received, and triage status. On average, elderly NH residents visited EDs at a rate of 123 visits per 100 institutionalized persons. Nearly 15% of all ED visits had ambulatory care sensitive condition diagnoses. Nearly half of these visits resulted in hospital admission; chronic obstructive pulmonary disease, congestive heart failure, kidney/urinary tract infection, and dehydration were associated with higher odds of admission. Previous studies suggested that adequate medical staffing and appropriate care in the NH could reduce ED visits and hospital admissions. Recent initiatives seek to reduce ED visits and hospitalizations by providing financial incentives to spur better coordination between NH and hospital.
1
National Center for Health Statistics, Hyattsville, MD, USA
Corresponding Author: Chun-Ju Hsiao, National Center for Health Statistics, 3311 Toledo Road, Hyattsville, MD 20782, USA. Email: [email protected]
Downloaded from roa.sagepub.com at UNIV OF CONNECTICUT on June 17, 2015
208
Research on Aging 36(2)
Keywords ambulatory care sensitive conditions, hospital admissions, long-term care
Emergency departments (EDs) are used by nursing home (NH) residents at rates almost 5 times higher at ages 65–74 and almost 3 times higher at ages 75 and older than their noninstitutionalized counterparts (McCaig & Burt, 2005). Almost half of ED visits made by NH residents resulted in hospitalizations (Wang, Shah, Allman, & Kilgore, 2011). Further research is needed to characterize whether ED visits by this population, particularly those eventually hospitalized, can be reduced or avoided. This study uses nationally representative data to examine characteristics of ED visits made by elderly NH residents as well as factors associated with hospital admission from the ED. This study specifically focuses on the relationship of ED visits and subsequent inpatient hospitalization with ambulatory care sensitive conditions (ACSCs).
Description of the Problem Prior research found that NH residents present at EDs with greater medical acuity and complexity than their noninstitutionalized counterparts (Wang et al., 2011). When NH residents are transferred to EDs, their care is often fragmented with little continuity of care between the NH and hospital (Ackermann, Kemle, Vogel, & Griffin, 1998). Information critical to effective emergency care such as the mental status and medical conditions of NH residents is often not available to ED staff (Ackermann et al., 1998; Zimmer, Eggert, Treat, & Brodows, 1988). In addition, obtaining a complete and accurate medical history is often difficult for ED staff when cognitive problems exist among these patients (Vladeck, Miller, & Clauser, 1993). Thus, lack of information and the frail health of these patients pose challenges to the hospital and ED staff. If the ED visit results in admission to the hospital, the stay itself may be hazardous for the elderly NH resident. Studies have reported that the elderly commonly experience functional decline, delirium, iatrogenic illnesses, and other adverse events during hospital stays (Covinsky et al., 2003; Creditor, 1993; Ebersole & Hess, 2001; Inouye et al., 1999). In addition, there are cost and efficiency concerns associated with hospitalization of NH residents. A study showed that the average spending for NH resident’s hospitalization with any ACSC was $10,140. Among ACSC hospitalizations, asthma, pneumonia, and diabetes
Downloaded from roa.sagepub.com at UNIV OF CONNECTICUT on June 17, 2015
Hsiao and Hing
209
were the most costly conditions (Grabowski, O’Malley, & Barhydt, 2007). The average cost of ED visits for people age 65 and up was $1,306 (Agency for Healthcare Research and Quality, 2009). The cost for ED visits could be higher for NH residents because of their greater medical acuity and complexity. Due to the problems that NH residents encounter in the ED, some researchers have examined the extent of unnecessary ED visits and hospital admissions from EDs among the NH population (Irvine, Van Buren, & Crossley, 1984; Kerr & Byrd, 1991; Stark, Gutman, & McCashin, 1982). However, most of the data are outdated or derives from a single ED or NH. One study used 2004 national data to examine potential preventable ED visits by NH residents, but it used reason for visit, instead of the actual diagnosis to classify potentially preventable ED visits (Caffrey, 2010). In addition, the study did not have information on ED visits, nor whether such visits resulted in a subsequent inpatient admission or not. The Institute of Medicine (IOM) has recommended use of hospitalizations for ACSCs as an indicator for whether appropriate care was provided to avoid hospitalization (Institute of Medicine [IOM], 1993). The IOM’s ACSCs indicator has been used increasingly to examine the appropriateness of ED visits by NH residents and subsequent hospitalizations (Carter, 2003; Carter, Datti, & Winters, 2006; Carter & Porell, 2005; Grabowski et al., 2007; Intrator, Castle, & Mor, 1999; Intrator, Zinn, & Mor, 2004). A study used 2000–2002 National Hospital Ambulatory Care Survey (NHAMCS) data to compare ACSCs among ED visits made by older adults inside and outside of NHs. The study found higher risk for ACSCs and hospitalizations for NH residents compared with their noninstitutionalized counterparts (Carter et al., 2006). A more recent study used 2005–2008 NHAMCS data to characterize ED use by NH residents, but it did not examine characteristics associated with hospital admissions from EDs (Wang et al., 2011).
Purpose We use national data from 2001 to 2008 to examine ED use and subsequent hospital admission among NH residents. The large sample size permits more detailed analyses with two specific aims: (1) evaluate and characterize ED visits made by NH residents, including whether the ED visit resulted in hospital admission: and (2) examine whether presence of ACSCs was associated with hospitalization from the ED.
Downloaded from roa.sagepub.com at UNIV OF CONNECTICUT on June 17, 2015
210
Research on Aging 36(2)
Method Data Source The study is based on nationally representative samples of ED visits collected in the 2001–2008 NHAMCS. The scope of NHAMCS is patient visits to EDs and outpatient departments of non-Federal, short stay, or general hospitals. For the purpose of this study, we only use data from the ED component of the NHAMCS. NHAMCS employs a four-stage probability sample design involving samples of geographic primary sampling units (PSUs), hospitals with EDs within PSUs, emergency service areas (ESAs) within EDs, and patient visits within ESAs. The final sampling stage involves a systematic random sample of ED visits during a randomly assigned 4-week reporting period. The U.S. Census Bureau, acting as the data collection agency for the survey, provided training to field representatives throughout the nation who, in turn, oversaw data collection at the hospital. Hospital staff were instructed to complete the information requested on the patient record form. During 2001–2008, data were collected for 287,803 sampled ED visits from non-Federal, short stay, and general hospitals. During this time period, the average number of participating hospital EDs was 367. The unweighted response rate for each year ranged from 85.3 to 91.9% (McCaig & Burt, 2003, 2004, 2005; McCaig & Nawar, 2006; National Center for Health Statistics [NCHS], 2010; Nawar, Niska, & Xu, 2007; Niska, Bhuiya, & Xu, 2010; Pitts, Niska, Xu, & Burt, 2008).
Measurement The information regarding patient residence on the patient record form was collected in two different manners across the years. From 2001 to 2004, NH residents were identified by the question ‘‘Does the patient reside in a NH or other institution?’’ From 2005 to 2008, the NH residence was among several response choices for patient residence. Although it is possible that some ED visits with positive responses to the question in 2001–2004 may have been in an institution other than a NH (e.g., prison, mental hospital), we limited this possibility by focusing our analysis exclusively on ED visits among the elderly (i.e., those aged 65 or older). We also compared 2001–2004 estimates with 2005–2008 combined estimates for potential differences due to question wording and found no statistical differences in estimates. In our analysis, ED visits among patients whose place of residence was marked as unknown were assumed to reside in the community based on the similarity of characteristics for these cases with those responding ‘‘No’’ in 2001–2004 or ‘‘private
Downloaded from roa.sagepub.com at UNIV OF CONNECTICUT on June 17, 2015
Hsiao and Hing
211
residence’’ in 2005–2008. Basic characteristics of ED visits in 2001–2004 versus 2005–2008 were generally very similar (data not shown).
Statistical Analysis We conducted two types of analyses in the study. The descriptive analysis characterizes ED visits by NH residents and the second analysis models the likelihood of hospitalization among NH residents’ ED visits. The descriptive analysis includes the average annual ED visit rates among elderly NH residents per 100 institutionalized persons during 2001–2008. ED visit rates were calculated by dividing the estimated count of ED visits among the elderly NH residents by estimates of the civilian institutionalized population in each cohort of interest for the same years, overall, by age (65–74, 75–84, 85þ), sex, and race (White, non-White). For example, the visit rate for males was obtained by taking the weighted ED visits made by males divided by the male institutionalized population estimated by the Census Bureau. The institutionalized population estimates were derived by subtracting estimates of the civilian noninstitutionalized population from estimates of the civilian resident population as of each year during 2001–2008. Each set of annual population estimates are projections based on Census 2000 data developed by the Population Division, U.S. Census Bureau using the July 1 set of state population estimates (U.S. Census Bureau). The descriptive analysis also summarizes the services ordered or provided during ED visits and outcomes of ED visits by elderly NH residents. We calculated the mean number of diagnostic or screening tests performed based on responses to a number of check boxes (ranging from 21 to 30 during 2001–2008) indicating whether any of the specific diagnostic or screening tests were ordered or performed. We also calculated the percent of ED visits among elderly NH visits that had each of the nine most frequent diagnostic or screening tests performed. In addition, we estimated the mean number and the percent of the five most frequent procedures performed from a list of possible procedures indicated (11 procedures for 2001–2006 and 13 procedures for 2007–2008). We also summarized information on triage status (nonurgent, semiurgent, urgent, emergent, or unknown/no triage), and disposition status (no follow-up planned, return if needed, return/refer to other physician or clinic, transfer to other facility, or admit to hospital). Finally, we compared the mean number of diagnostic tests and procedures as well as the percentage of subsequent hospitalization between ED visits with and without ACSCs. To examine the relationship between ACSCs and hospitalization following ED visits, a multivariate logistic regression model was performed. The
Downloaded from roa.sagepub.com at UNIV OF CONNECTICUT on June 17, 2015
212
Research on Aging 36(2)
dependent variable for the model was whether the visit resulted in admission to the hospital. Patients who were dead on arrival or died in ED were excluded from the logistic regression. The main independent variable was the presence of ACSCs. Presence of ACSCs was determined by the first-listed diagnosis as coded by the International Classification of Diseases, 9th Revision, Clinical Modification codes as developed by Millman et al (IOM, 1993). The first-listed diagnosis is the diagnosis to which the ED visit has been attributed. The list of 13 ACSCs included grand mal seizure disorders, severe ear, nose, and throat infections, chronic obstructive pulmonary disease (COPD), bacterial pneumonia, asthma, congestive heart failure (CHF), hypertension, angina, cellulitis, diabetes, hypoglycemia, kidney/urinary tract infection, and dehydration. In the multivariate model, we also controlled for several possible confounders based on the Andersen model of health services use (Aday & Andersen, 1974). The predisposing components include variables that describe individuals’ tendency to use services. The enabling components represent the means that are available to individuals for the use of services, including both resources to the individual and family as well as attributes of the community. The need components refer to illness level. The need components are hypothesized to be the most immediate determinants of health service use while the predisposing components are the most distant determinants. In this article, predisposing factors included age (65–74 years, 75–84 years, 85 years, and over), sex, race (White, non-White). Enabling factors included expected payment source (private insurance, Medicare, Medicaid, other) and metropolitan statistical area (MSA) status (yes, no). In addition to ACSCs, need factors included number of procedures (0–1, 2, or more), number of ED diagnoses (0–1, 2, or 3), and triage information (
