Is geriatric care associated with less emergency department use?

Abstract

Objectives: To determine whether community-dwelling individuals and nursing home (NH) residents treated by a geriatrician were less likely to use the emergency department (ED) than individuals treated by other physicians.

Design: Retrospective cohort study using data from a national sample of older adults with a history of cardiovascular disease.

Setting: Ambulatory care or NH.

Participants: Fee-for-service Medicare beneficiaries aged 66 and older diagnosed with one or more geriatric conditions from 2004 to 2007 and followed for up to 3 years.

Measurements: Emergency department use was measured in Medicare inpatient and outpatient claims; geriatric care was measured as geriatrician visits in ambulatory or NH settings coded in physician claims.

Results: Multivariable analyses controlled for observed and unobserved subject characteristics that were constant during the study period. For community-dwelling participants, one or more nonhospital geriatrician visits in a 6-month period were associated with 11.3% lower ED use the following month (95% confidence interval (CI) = 7.5-15.0, N = 287,259). Participants who received primary care from geriatricians were less likely to have ED use than those who had traditional primary care. Results for participants who received consultative care from geriatricians were similar to those for participants who received primary care from geriatricians. Results for NH residents (N = 66,551) were similar to those for community-dwelling participants.

Conclusion: Geriatric care was associated with an estimated 108 fewer ED visits per 1,000 community-dwelling residents and 133 fewer ED visits per 1,000 NH residents per year. Geriatric consultative care in collaboration with primary care providers may be as effective in reducing ED use as geriatric primary care. Increased provision of collaborative care could allow the existing supply of geriatricians to reach a larger number of individuals.

Figure 1. Sample Selection

ACS = acute coronary syndromes ^aStroke (International Classification of Diseases, Ninth Revision (ICD-9) codes 430.xx–432.xx, 434.xx–437.1x, 437.3x–438.xx), dementia (290.0–290.43, 294.0–294.8, 331.0–331.2, 331.7, 797), depression (300.4, 301.12, 309.0, 309.1, 311), delirium (293.0x, 293.1x), pressure ulcer (707.0x, 707.2x–707.9x), fracture (800.xx--829.xx), dislocation (830.xx–839.xx), laceration (870.xx–879.xx, 880.xx–884.xx, 890.xx–894.xx), osteoporosis (733.0), syncope (780.2), hearing impairment (389.xx), vision impairment (369.xx), urinary incontinence (596.51–596.52, 596.54–596.59, 599.8x, 625.6x, 788.3, 788.30–788.34, 788.37–788.39), weight loss/failure to thrive (260–263.9, 783.21–783.22, 783.7x), or dehydration (276.5) ^bMost patients with missing data had missing income data; their ZIP code did not match a ZIP code tabulation area in the 2000 Census ^c26,875 patients were in both samples

Figure 2. Study Timeline

ACS = acute coronary syndromes ED = emergency department

Figure 3. Percent Change in Predicted Probability of Emergency Department Use in One Month Associated with Geriatric Care

NH = nursing home Notes: 95% confidence intervals shown. Models control for demographic variables, geriatric conditions, comorbidities, month indicators, and time trends. Percent change calculated as change in predicted probability of emergency department (ED) use (not reported) divided by the sample mean of ED use (Table 1) multiplied by 100. For example, for community residents, the reduction in ED use associated with ≥1 geriatrician visits was 0.9 percentage points; compared to the sample average of 8.0% for ED use for community residents, the result is an 11.3% decrease in ED use.

Figure 3. Percent Change in Predicted Probability of Emergency Department Use in One Month Associated with Geriatric Care

NH = nursing home Notes: 95% confidence intervals shown. Models control for demographic variables, geriatric conditions, comorbidities, month indicators, and time trends. Percent change calculated as change in predicted probability of emergency department (ED) use (not reported) divided by the sample mean of ED use (Table 1) multiplied by 100. For example, for community residents, the reduction in ED use associated with ≥1 geriatrician visits was 0.9 percentage points; compared to the sample average of 8.0% for ED use for community residents, the result is an 11.3% decrease in ED use.