We observed a pluralistic pattern of ED use among a nationally representative sample of older adults. Nearly 1 out of every 5 (17.2%) older adults persistently presented to the ED with clinically severe conditions; a second group constituting an additional 20% of persons over 65 persistently presented with non-severe conditions; and a third group representing slightly more than 21% of older adults persistently presented with a pattern of indeterminate episodes. These groups differed from each other in significant ways. Individuals with a persistent pattern of presenting to the ED with severe episodes were more likely to be older, male, and have chronic disease conditions, such as diabetes, heart disease, and hypertension, and greater levels of morbidity than those with persistent patterns of non-severe and indeterminate ED episodes. These findings provide more evidence for empirically well-established associations among age, health and service use .
In considering these results further, we observed that cardiac dysrhythmias and heart failure accounted for more than 30% of the severe episodes, suggesting that as individuals with heart disease aged, they acquired conditions which contributed toward persistently presenting to the ED with clinically severe needs. Assuming that the ED remains a primary point of service contact for this large group of older individuals with severe clinical problems, the demand placed on staff and resources will become substantial as the aging population grows in the coming decade . As such, ED providers should consider developing geriatric protocols and increasing the supply of staff trained in geriatric assessment and care management [2, 35]. Alternatively, efforts could be directed toward developing population management programs that reduce ED use among those with diabetes, heart disease, and other co-morbidities that are associated with persistently severe ED patterns. For example, by enrolling persons with diabetes into patient education programs or enlisting people with cardiovascular disease into chronic disease management programs, the patterns of older individuals who persistently use the ED for severe conditions may be beneficially altered as they have been with other populations [36–38].
We hypothesized that individuals who persistently use the ED for less severe episodes would differ in terms of their access to services and continuity of care, expecting our findings would support efforts that focus on readily modifiable variables as a way to address the excess demand created by this large group. Although we found that both the persistently severe and persistently non-severe groups were more likely to live in rural areas than persons with persistently indeterminate patterns of ED use, we found no other significant differences in terms of local service supply or continuity of care.
We also hypothesized group differences might be related to potentially modifiable, previously unexamined health behaviors such as obesity or smoking. Our results, however, did not provide a clear picture. Persons with persistently severe patterns of ED use were more likely to be current smokers than those with persistently non-severe patterns, but they were no different than those with persistently indeterminate patterns. Alternatively, persons with persistently severe patterns were more likely to be obese compared to persons with persistently indeterminate episodes, but they were no more likely to be obese than those with persistently non-severe patterns.
Still our (lack of) findings provide some support that older individuals who persistently bring less severe conditions to the ED may be electing to bypass readily available community-based alternatives. In particular, given that we found no differences between the groups in terms of education, income and supplemental insurance coverage, it is plausible to contend that the nearly universal coverage afforded by Medicare has mitigated any sensitivity older adults may have to deductible and co-payment obligations, and thus, perhaps they view their use of the ED comparably to their use of primary care [28, 37]. Indeed, others have contended that the ED has become a substitute for primary care because individuals have resolved that the ED is comparable if not superior to primary care, offering immediate access, a full range of diagnostic and treatment services, and a more definitive resolution to their presenting complaint .
If this large and growing population of older adults is in fact insensitive to using the ED relative to primary care, then their demand for the ED will continue to increase. Perhaps future research efforts could examine how altering deductible and co-payment obligations might affect service use patterns so that those who persistently present with non-severe conditions become more sensitive about using the ED when community-based alternatives are available [12, 40].
Finally, in comparing across and within the persistently severe and persistently non-severe groups based on the frequency of ED use, our results indicated that the differences were more definitive among those with fewer ED episodes. As a person aged and the frequency of ED episodes increased, the group differences became less pronounced. These particular findings substantiate the difficulty in trying to develop a management approach that targets individual visits at any given point in time.
This study is not without limitations. First, no data were available on the EDs to which the individuals presented, and we were unable to reduce the heterogeneity of these EDs in terms of capacity, staffing, and procedural policies. Second, although we noted there were other older ED users in the AHEAD sample, our analysis was limited in that we did not include ED use for trauma, drug, and alcohol situations and did not include these persons in the group comparisons.
Nonetheless our work further illuminates the intersection between older adults and their use of the ED. In observing ED episodes over an extended observation period and testing an expanded model, we affirmed previous findings about the relationship between age, health status and persistent use of the ED for severe conditions. Future research might examine how targeted efforts to manage population groups that persistently present with severe conditions might alter ED use. We also found that while older adults who persistently present to the ED with non-severe conditions may not experience problems with access and continuity or clearly differ in terms of modifiable health behaviors, they may be price insensitive and consider the ED as a substitute for primary care. Perhaps future research could further examine insurance and claims data and test if variations in coverage corresponded with differing patterns of ED use for other groups (i.e., Medicaid eligibles) who persistently present with non-severe conditions.