In our sample of 1168 elderly patients from 124 EDs in France, a third were assisted by professional home services while over half of them had access to informal caregivers (such as friends or relatives). There was no association between in hospital mortality and professional home services. Assisted patients had a similar risk of being admitted after ED visit but were associated to a lower risk of being admitted for « having difficulties coping at home ».
The rate of elderly patients assisted by home services matches other published research dealing with elderly population living alone at home [19]. However, the present study detailed professional home services for elderly patients visiting EDs, investigating their dedicated tasks also providing a full profile of this specific population while exploring their emergency resources use and outcomes.
The admission rate reported in this study was superior to those mentioned in literature about geriatric populations but definitions of elderly have varied over the past 20 years depending on publications, which is a limit for comparisons [1, 4, 20]. The DREES survey conducted in 2013 in 736 French EDs noted that elderly patients counted for 12% of the emergency flow and 56% among those were admitted following their visit [20]. However, the present study focussed on visiting patients who lived by themselves at home whereas the DREES survey included elderly patients living in healthcare facilities whose admission rate is usually lower [4]. Otherwise, characteristic features in terms of comorbidities, investigations and primary diagnosis were similar to those noted in literature. Elderly patients are polypathological, come in the forts place for traumatological motives and are given more investigations than younger patients [1, 3, 4]. Finally, the mortality rate as observed in EDs was similar to those noted in other French studies [21, 22].
When comparing both groups, assisted patients suffered more comorbidities (notably cardiovascular, respiratory and neurological) and suffered more frequently from loss of autonomy (whether measured with Knaus classification or the ADL score). After adjusting for those factors, it appears that the in-hospital mortality was not tied to the presence of at home services but was associated to the severity of the acute illness when reaching the ED as well as to the patient’s level of autonomy. Results associating autonomy level and short-term mortality after ED visits was consistent with literature on the subject [7, 8]. The degree of autonomy is already a decisive and essential information in emergency settings in order to allow physicians to make urgent decisions such as engaging in resuscitation manoeuvres [9].
Nevertheless, the risk to be admitted for «having difficulties coping at home» was lower for patients with available home services. This suggests a form of substitutability between at home professional services and the resort to hospital care. However, these services are often regulated outside the scope of health policy. Whereas a number of evaluations of the economic impact of this developing area of activity exist, few studies investigate the sanitary and social benefits of increasing at home support [15, 16]. The French PAERPA program was dedicated to the implementation of a coordination process of already existing home services and its assessment was focussed on various health indicators (visit to EDs, avoidable admissions). Preliminary results did not demonstrate any effect on the different factors under study [23]. However, it did not investigate the implementation of home services for elderly individuals that were lacking home support. The present study found that some patients that were not assisted by home services exhibited a high level of dependency. Combined with the lower rate of admission for «having difficulties coping at home», this suggests on the contrary that public investment bearing on the development of at home support could result in a reduction of part of admissions following ED visits. Adequate care at home for dependency through professional services might have an incidence on the pathway of care for elderly patients and could result in avoiding some admissions and their corollary complications (iatrogenic dependence, lengthening of hospital stay, mortality) [2, 3, 24].
Limitations
Our study has some limits. In spite of the high number of EDs participating our sampling did not aim at being representative of French EDs as a whole. Thus, the results presented here cannot be extrapolated to other contexts. However, the patients’ profile appears consistent with results achieved in other large-scale studies.
In addition, we noticed differences in the descriptive characteristics of the two compared groups: assisted patients are more likely to present comorbidities, are more often polymedicated and have lower level of autonomy. We tend to compensate this distortion of comparability through multivariable analysis adjusting for these factors even if biases may remain despite the chosen set of adjustment variables. However, even though we noticed differences between the characteristics of the two groups, there are still patients that are not assisted by professional home services presenting with low autonomy level, polymedication and comorbidities; conversely, substantial proportions of assisted patients are autonomous, have no comorbidities, are not polymedicated and have few comorbidities. This should allow the multivariable adjustments to be effective. Furthermore, the in-hospital mortality rate is not associated to professional home services even after adjusting for these characteristics. Similarly, the ED outcomes do not differ when adjustments are made. Thus, these are indications that multivariable adjustments should be considered as effective.
Our study revealed a significant proportion of dependent patients lacking professional support. However, we were not able to document more precisely the causes of this lack of professional services use, notably in relation with socio-economic characteristics. Nevertheless, studies exploring the use of home services by elderly individuals point to a strong correlation with income level [15, 25]. Financial barriers exist. The cost’s impact of services on the household disposable income depend on the global income and social context. In France, various financial support systems assume part of the induced cost but administrative processes are complex resulting in a high rate of elderly individuals forgoing these administrative aids [17].
Finally, to consider “having difficulties coping at home” as one of the diagnostics justifying hospital admission relied on the local investigator’s judgment. That situation refers to an inadequate balance between the patient’s functional resources and the constraints and complications that returning home might precipitate. Although it gets used in an empirical and informal fashion as a motive for hospitalization, no precise definition exists of this notion. In consequence, no guarantee can be given of its reproducibility between practitioners so that a classification bias may have intervened and may have produced an under- or overestimation of the parameter. Those subjective decisions, in spite of a potential classification bias, have impacted for good the way patients have been taken care of and hospitalized, which points to the importance of the link between the daily care for dependent patients at home and the pathway followed by elderly patients once visiting EDs.
