The Temporal Trend in the Transfer of Older Adults to the Emergency Department for Traumatic Injuries: A Retrospective Analysis According to Their Place of Residence

Factors Associated with Potentially Inappropriate Transfer to the Emergency Department among Nursing Home Residents

OBJECTIVES

To determine the factors associated with the potentially inappropriate transfer of nursing home (NH) residents to emergency departments (EDs) and to compare hospitalization costs before and after transfer of individuals addressed inappropriately vs those addressed appropriately.

DESIGN

Multicenter, observational, case-control study.

SETTING AND PARTICIPANTS

17 hospitals in France, 1037 NH residents.

MEASURES

All NH residents transferred to the 17 public hospitals' EDs in southern France were systematically included for 1 week per season. An expert panel composed of family physicians, emergency physicians, geriatricians, and pharmacists defined whether the transfer was potentially inappropriate or appropriate. Residents' and NHs' characteristics and contextual factors were entered into a mixed logistic regression to determine factors associated independently with potentially inappropriate transfers. Hospital costs were collected in the national health insurance claims database for the 6 months before and after the transfer.

RESULTS

A total of 1037 NH residents (mean age 87.2 ± 7.1, 68% female) were transferred to the ED; 220 (21%) transfers were considered potentially inappropriate. After adjustment, anorexia [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.57-3.71], high level of disability (OR 0.90, 95% CI 0.81-0.99), and inability to receive prompt medical advice (OR 1.67, 95% CI 1.20-2.32) were significantly associated with increased likelihood of potentially inappropriate transfers. The existence of an Alzheimer's disease special care unit in the NH (OR 0.66, 95% CI 0.48-0.92), NH staff trained on advance directives (OR 0.61, 95% CI 0.41-0.89), and calling the SAMU (mobile emergency medical unit) (OR 0.47, 95% CI 0.34-0.66) were significantly associated with a lower probability of potentially inappropriate transfer. Although the 6-month hospitalization costs prior to transfer were higher among potentially inappropriate transfers compared with appropriate transfers (€6694 and €4894, respectively), transfer appropriateness was not significantly associated with hospital costs.

CONCLUSIONS AND IMPLICATIONS

Transfers from NHs to hospital EDs were frequently appropriate. Transfer appropriateness was conditioned by NH staff training, access to specialists' medical advice, and calling the SAMU before making transfer decisions.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02677272.

Characterizing Emergency Department Use in Assisted Living

OBJECTIVES

Little is known about emergency department (ED) utilization among the nearly 1 million older adults residing in assisted living (AL) settings. Unlike federally regulated nursing homes, states create and enforce AL regulations with great variability, which may affect the quality of care provided. The objective of this study was to examine state variability in all-cause and injury-related ED use among residents in AL.

DESIGN

Observational retrospective cohort study.

SETTING AND PARTICIPANTS

We identified a cohort of 293,336 traditional Medicare beneficiaries residing in larger AL communities (25+ beds).

METHODS

With Medicare enrollment and claims data, we identified ED visits and classified those because of injury. We present rates of all-cause and injury-related ED use per 100 person-years in AL, by state, adjusting for age, sex, race, dual-eligibility, and chronic conditions.

RESULTS

Risk-adjusted state rates of all-cause ED visits ranged from 100.9 visits/100 AL person-years [95% confidence interval (CI) 92.8, 109.9] in New Mexico to 162.3 visits/100 AL person-years (95% CI 154.0, 174.7) in Rhode Island. The risk-adjusted rate of injury-related ED visits ranged from 18.7 visits/100 AL person-years (95% CI 17.2, 20.3) in New Mexico to 35.7 visits/100 AL person-years (95% CI 34.7, 36.8) in North Carolina.

CONCLUSIONS AND IMPLICATIONS

We observed significant variability among states in all-cause and injury-related ED use among AL residents. There is an urgent need to better understand why this variability is occurring to prevent avoidable visits to the ED.