This study aimed to analyse the trajectories in the last decade of the percentage of ED users among NH residents in the Italian health care system, investigating determinants for admission to the EDs among demographic, health supply and clinical/functional variables.
The analysis showed a decline in the percentage of ED users over the past 8 years. A decrease was reported for all chronic conditions at the NH admission, even though it occurred in a heterogeneous manner. It is not easy to explain the reason for this significant decline, also because there have been no specific policy actions that would have resulted in substantial changes to care delivery over time. However some explanations may account for this finding. This result may have been facilitated by strengthening of the type of care model adopted in the Italian health care system, which is characterized by some fundamental elements. First, the multidimensional evaluation of the person; second, the drafting of a care plan by a multiprofessional and multidisciplinary team. This model consents to provide integration of care, clinical review, support, and management of the acutely or chronically unwell resident in NH. This suggestion is in keeping with findings from previous studies showing that Care models that enhance the nursing home’s capacity to provide on-site evaluation and management of acute changes through early recognition, monitoring, and staff have been shown to decrease the number of ED visits among nursing home residents without increased mortality rates [14, 15].
This result may have been influenced by the type of health care system within which our study took place. The National Health Service (NHS), by Laws: March 11th 1988, n. 67 – art. 20 and Decree of the president of the council of ministers (DPCM) on January 12, 2017 [2], guarantees, through public resources, the opportunity to stay in nursing homes to people who are not self-sufficient and who are unable to care for themselves at their home. The suggestion that our results may be affected by the type of health care system is in agreement with a previous study reporting that for older people (≥ 75 years), the availability of beds in nursing homes was inversely associated with ED visit rates [16]. This suggestion is reinforced considering that, in our study, most of the residents were over 80 years old.
According to the results, some residents’ demographic characteristics and functional variables reduce odds to ED visits.
The results showed that a nonfrequent ED user may be > 90 or be female.
Although it is already known that males are more predisposed to ED visits [8], a review concluded that the influence of age is not very clear in the literature due to the heterogeneity of outcomes and methods of most of the studies, mostly because studies used different age categories or assessed age as a continuous variable [8]. However, other literature confirms our results. A review reported that ED visits seemed to decline with increasing age, especially > 80–85 years [17], and similarly, a study identified NH residents younger than 75 years as a group at greatest risk for ED visits [18].
Additionally, according to our study, residents with severe impairment have lower odds of ED use. This finding is not surprising and consistent with those of previous studies. Compared with residents with mild cognitive impairment (CI), an American study in 2011 [19] showed that the adjusted odds ratio of ED visits decreased as the severity of CI increased and that residents with severe CI had up to a 40% lower odds of visiting the ED [20]. Another study reported that advanced CI appears to be protective against the odds of ED visits [21]. The literature offers different suggestions to explain this result. On the one hand, this suggests that residents with mild severity CI have a higher risk of visiting the ED, probably because those individuals were not yet been formally diagnosed with a cognitive impairment. In the early stages of CI, patients may exhibit symptoms that create the uncertainty regarding how to treat them, thereby leading to transfer of the resident to the ED [20]. Alternatively, the literature suggests that the result of a decreasing ED visit trend for those who have severe CI may be explained by the good recognition of the negative consequences for this vulnerable group of ED transfer that would accelerate their functional declines [21]. To these suggestions, it can be added that it is more likely that patients suffering severe cognitive impairment are treated with a more palliative or with a comfort care approach, making them less likely to visit the ED [18, 19].
Not surprisingly, residents dependent on ADL appeared to have reduced odds of ED use. This result is consistent with previous studies showing that residents who had moderate ADL dependence had a greater odds of making ED visits [18, 22]. It is realistic to assume that residents with greater ADL need are the subject of greater attention from the team of health workers in order to avoid future ED use for falls, skin disorders, and dehydration occurring with greater frequency among older adults who do not have fully met ADL [23].
Another important and expected result was that the absence of problem behaviours reduced the odds of ED use. Indeed, having behavioural problems, such as apathy, agitation or aggression, is known to be associated with a diminished quality of life for NH residents, as well as worse patient–physician/nurse care relationships. In addition, behavioural problems are often treated with antipsychotics, which may have negative side effects [24, 25]. In essence, either for their presence or their treatment, behavioural problems increase the complexity of care and the professional uncertainty surrounding the proper treatment [22], increasing the need for ED use.
To our knowledge, this is the first study to examine ED user trends among NH residents over almost a decade in a large Italian region. The findings of the present study have multiple policy implications. First, the declining trends of ED users suggest NH managers foster an assistance model based on a holistic approach that is able to offer continuity of care and ad hoc treatment for every patient’s need, either physical, psychological or social. Indeed, in Italy, this holistic approach was supported by the DPCM 12/01/2017, [4] which provides for a multidimensional assessment that considers clinical, psychological and sociofamily dimensions and explores the various factors that can configure the condition of fragility through various qualitative and quantitative measuring instruments. The multidimensional assessment allows the redaction of the individualized care plan. This plan in Italy is one of the minimum organizational requirements for a NH, and it is a fundamental document that summarizes the conditions in which the person finds himself and defines a personalized approach developed to favour a condition of life, health and dignified well-being. In addition, this plan is provided by a team that guarantees medical care delivered by the general practitioner or own doctors and specialist care provided by the healthcare workers of ASL. This access to medical care supports avoidance of ED visits.
Second, the declining trends of ED users seem to confirm the effectiveness of the LTC model, it should be implemented by policy-makers, keeping in mind the importance of reducing transfers for elderly or fragile patients due to their negative consequences in terms of mortality and adverse clinical effects [9] A positive push in this direction is given in Italy thanks to the incoming Piano Nazionale di Ripresa e Resilienza (PNRR), which provides funding for fundamental matters such as digital health and telemedicine that also comprehends eConsults with specialists and other professionals [26]. In this way, it will become easier to monitor and treat patients more frequently in the same structure and daily setting, providing them with more stability and quality of care. This means that eConsults improve access to specialist advice, even containing costs, and provide a way to reduce ED use that requires family assistance or specialized services because of patients’ frailty [27, 28]. Some studies have demonstrated the feasibility of telemedicine in NHs to reduce ED utilization. These studies report a reduction of ED usage by 18–46%, without increasing GP visits or mortality [3].
The results and implications of this study must be considered in light of the study’s limitations. The main limitations are those of the databases used and are common to all administrative database studies. First, there are problems related to the quality of the NH data, especially with regard to the possible lack of accuracy and completeness of information across individuals and institutions. Even taking this weakness into account, these databases are the best available sources, suitable for wide epidemiological studies on the prevalence and incidence of major diagnoses or diseases and for monitoring population trends in the utilization of services. Another limitation of this study is that the NH residents were drawn from one country. Nevertheless, we have gathered information on a large cohort of patients over a long observation period across settings. Due to the study being performed in a large northern Italian region that has a health care system and population health profiles comparable to those of other European countries [29], our results may be helpful and useful for providing a comparison to other future analyses of ED visits from other countries.
