The association between living alone and health care utilisation in older adults: a retrospective cohort study of electronic health records from a London general practice

In 2016 one in three older people in the UK were living alone, an increase of 16% over two decades [1–3]. To address the complex health needs of older people who are often living with multiple-long term conditions [4], commissioners and clinicians often attempt to identify those at highest risk of hospital admission to target with additional clinical community care and enhanced social support [5–7]. However, there has been limited success in the application of such care models, perhaps because the majority of risk stratification tools use only selected clinical data and do not consider patient preferences or the wider social support a patient may have access to in their home, family or the community [7–9].

Although it is widely accepted that a person’s living arrangements are influential on their health [10–12], few studies have examined the association between living arrangements and health care utilisation. While some existing studies have shown an association between living alone, or households with only older people, and increased health care utilisation [13–17], other UK-based studies have not found the same effect [18, 19]. However, many of these studies rely on survey data or self-reported utilisation [13–15, 18, 19]; analyse patterns at a practice rather than at an individual patient level [16]; or focus on only one element of health care services [13, 15–17]. The results of existing studies provide conflicting evidence of the impact of living alone on health care utilisation, this study adds to the literature by examining the relationship at a patient level using electronic health records.

In this study, we assess the relationship between living alone and primary and secondary care utilisation in the English NHS by using electronic health records from a large multi-site general practice, linked at the individual patient address level. Such datasets are increasingly available for use in quality improvement, thus our findings have widespread applicability. We focus our study on older patients as this population is at particular risk of both hospital admission and isolation.

We analysed 1447 older patients and examined the association between living alone and four types of health care utilisation. After controlling for patient demographic and clinical characteristics, older patients living alone were 50% more likely to have an emergency department attendance and 40% more likely to have over 12 general practitioner appointments compared to older patients living with others. Given there is a growing population of older people living alone with complex health needs [1, 4] and patients living alone have higher health care services utilisation, there are substantial implications for the increasing pressure on general practice and acute care services.

The relationship between living alone and health care utilisation is more pronounced in patients aged 70 and over, and amongst the highest users of health care services. We also found that those living alone, and aged over 80 were less likely to utilise outpatient appointments. These results highlight the usefulness of data collected in electronic health records to understand non-clinical factors, such as whether a patient lives alone, when designing interventions intended to improve quality of care for patients, and reduce demand for secondary care [23].

To our knowledge our study is the first in the UK to examine this question using electronic health records, and so a direct comparison is not possible, though our findings do contradict those presented in the most comparable UK study. The existing study found that those living alone had lower general practitioner utilisation, odds ratio 0.78 (95% CI 0.6–1.0), while we show that those living alone had significantly higher general practice utilisation, odds ratio 1.40 (95% CI 1.04–1.88) [18]. However, the results presented here are consistent with international studies conducted across health care systems in Mexico, the United States and Australia. Previous research has found an association between older people who live alone and increased health care services utilisation [13–17]. In an Australian study, patients who live alone have a 2.7% higher probability of accessing inpatient services [15]; and in a study conducted in London, there is a strong correlation between older patients living alone and emergency department attendances [16]. Despite differences in the structure of health care systems across the world, the results presented in this paper are consistent with the findings of international studies and provide additional evidence that older patients living alone are higher users of general practice and emergency services.

Our study has a number of strengths; unlike many existing studies [13–16, 18], we had access to pseudonymised patient electronic health records, from both primary and secondary care and could control for demographic and clinical characteristics, including many long-term conditions. Additionally, these records contained secondary care utilisation over the last year and household-level identifiers. As a result, we did not rely on self-reported information from survey data, a drawback of many of the existing studies. [13–15, 18, 19] Furthermore, the use of the data in this manner demonstrates that general practitioners can play an active role in the use of their routine data in identifying subgroups of patients who live alone and designing interventions that are suited to their needs.

This study is limited by several weaknesses. The electronic health records were all from one urban general practice in South-East London. Their relatively young and deprived population [20], may not be representative of England as a whole. Moreover, the provision of local health care and other services for older patients may vary geographically and may not be representative of England, though data was not available to examine this. No adjustment was made for clustering by practice site as the two sites were located close to one another and are subject to the same management. The secondary care utilisation was reported to Valentine Health by local secondary care providers and may be underestimated. However, there are no local policies or practices in place where reporting is more likely to be made for patients who live alone, and this should not impact on the conclusions of the study. Furthermore, it was not possible to separate out elective and emergency inpatient admissions as the reasons for inpatient admissions were not available. Data relating to homebased health and social care were not available, as a result it is not possible to account for the level of formal support patients may be receiving through these channels. This study only covers one year of utilisation; the impact of living alone, or the lifetime socioeconomic factors associated with living alone [24], may impact the severity of disease and other social factors [25], which in turn impact on health care utilisation. As our data was limited to patients registered at Valentine Health, our households could be missing those people registered at a different practice, or not registered at all. However, we would expect all older patients to be registered at a general practice, and most likely at the same one as the people they live with.

Our results demonstrate an association between older patient’s living arrangements and their health care utilisation. While the study design does not allow us to identify a causal link, it highlights the potential to identify and target patients with higher needs who live alone. Within primary care, there is scope for general practitioners to refer older people living alone to local non-clinical services, to help support them both emotionally and practically [26, 27] or review their care to identify potential areas of unmet need such as missed outpatient appointments. Within an acute care setting, interventions implemented prior to discharge which offer additional support to patients living alone may help reduce the risk of readmissions.

While this research demonstrates an association between living alone and health care utilisation, it does not explain the mechanism driving increased utilisation of health care services for older patients living alone. Although we controlled for deprivation, there may be wider social and deprivation factors that may influence both living arrangements and ill health, therefore increasing the demand for health services. One possibility is that social isolation and a lack of social support could result in poor health, and increased health needs for older patients living alone [28]. A second possible explanation is that patients who choose to live alone may not be either lonely or socially isolated, but may require increased support during periods of ill health, and utilise acute health care services meet this need. Further research is needed to determine whether acute care is the most appropriate setting to meet these needs, or whether there are other interventions that can be designed to meet these needs and to reduce the utilisation of acute care services.

Older patients living alone are 50% more likely to access emergency care services and 40% more likely to have more than 12 general practice appointments over a 12-month period, compared to the older patients not living alone. General practitioners can play an active role in identifying older patients living alone through routine data and providing additional support where required. The context of patients’ living arrangements has important implications for health care needs and the utilisation of health care services. Older patients who live alone may require additional support to support both clinical and nonclinical needs; identifying which individuals would most benefit from such support should be the target of further research.