Older adults account for more than 70% of Emergency Room to hospital admissions. And while there are many factors that influence admission rates, patient-level factors such as functional status, cognitive impairment, limited social supports, and syndromes specific to geriatric patients influence the decision to admit patients to the hospital; however, because these factors are not observable in administrative data, it is not known to what extent these patient-level factors impact hospital admissions.
When considering these factors, earlier studies have indicated they may influence admission rates, overall cost of care, and poorer outcomes, while other research has incorporated these factors into risk-adjustment models utilized to better calculate readmission and admission for ambulatory care sensitive conditions. However, it is still unclear which factors are most influential in the decision to admit patients.
In a recent study in JAMA Internal Medicine, Professor of Health Care Policy Bruce Landon, Professor of Health Care Policy Michael McWilliams, Gabriel Weinreb, and coauthors address this knowledge gap by evaluating several age-related variables and their impact on the likelihood of admission of elderly patients.
They used survey data from the Health and Retirement Study spanning from 2000-2018 and linked this to Medicare fee-for-service claims data to identify ED visits, and determine patient admissions, including 42,392 ED visits by 11.783 unique patients between 2000 and 2018.
To illustrate their findings, the authors constructed 6 vignettes representing different patient profiles with different levels of functional status, cognitive status, and social support.
They found that increased difficulty with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs) resulted in increased likelihood of admission. For example, difficulty performing activities of daily living and having dementia increased likelihood of admission by x percentage points, while living with a spouse or having children living within 10 miles markedly decreased the likelihood of admission. However common geriatric syndromes such as trouble falling asleep, vision problems, and depression were not significantly associated with admission rates.
Studies show that physicians are aware of the non-clinical factors and are careful to consider these when determining treatment plans for patients. However, with Health Systems under pressure from national payment reform initiatives to reduce wasteful spending, reducing avoidable hospital admissions is key. The study suggests that patient-level characteristics, including social support and cognitive and functional status are essential in reducing unnecessary ED visits and hospital admissions among older adults.
Including additional levels of support for patients with impaired functional status or lack of social supports has the potential to ensure safe outcomes while achieving reduced rates of admission. Combined with continued clinician consideration, better administrative data collection would allow for more accurate risk adjustment models. These, in addition to system interventions such as telemedicine, visiting nurses, and other modes of social support could cut down on unnecessary ED visits, reduce hospital admissions, and result in better outcomes for all patients.