Correspondence

Health services use by older adults in an urban public health system

To the Editor,

In addition to extensive use of the emergency department (ED) [1,2], older adults consume a disproportionate share of health care services in both ambulatory [3] and hospital settings [4]. We found no prior studies that place older adults’ use of the ED in the context of use of ambulatory care. The purpose of this investigation was to describe the use of the ED by a large cohort of older adults and compare the use of acute care services with the use of primary care services within the same health care system.

This study was a retrospective cohort analysis using data routinely collected and stored by a comprehensive electronic medical record. For each inpatient, ambulatory clinic, and ED encounter at any site within the targeted health care system, the Regenstrief Medical Record System routinely collects and stores clinical data [5].

The study population consisted of all patients aged 65 years and older who visited our system’s ED or Primary care clinics (PCCs) in 2001. We divided the study subjects into 3 cohorts. The first consisted of patients seen in the ED in 2001 but not seen in 1 of the 11 PCCs in 2001. The second cohort

included patients with at least one visit to one or more of the PCCs in 2001 but no ED visit in 2001. The third cohort included patients with both a primary care and an ED visit in 2001. Primary care included the ambulatory clinics staffed by general internal medicine, Family Medicine, or medicine- pediatric physicians. We also obtained data regarding the use of all Medical specialty and surgical clinics in our system. For comparative purposes, we obtained ED data for young adults, defined as patients aged 18 to 64 years.

This study was conducted within the Wishard Health System, a university-affiliated, urban, public health system that consists of (1) an ED with 106000 annual visits, (2) a hospital with 260 staffed beds, (3) 11 primary care centers, and (4) multiple outpatient specialty clinics. Wishard is the only tax-supported public health care facility in Indianapolis. We used v² tests to test for differences in dichotomous measures of demographics and health services use across the 3 cohorts, whereas analysis of variance models were used to test for differences of the continuous measures. In addition, we used t tests to test for differences for several comparisons that were valid for 2 groups. We presented charge data in actual dollars; however, all statistical tests were performed using the log transformation of the charge data. Charge data were transformed by adding 1 to all values

and then taking the natural logarithm.

0735-6757/$ - see front matter D 2005 doi:10.1016/j.ajem.2004.02.042

234 Correspondence

In a single year, there were 3731 different older adults cared for in this ED with a total of 7656 ED visits. More than 40% of elderly ED patients arrived by ambulance as compared to 18% of patients aged 18 to 64 years. The mean time in the ED for older patients was 7 hours 16 minutes with 27% admitted to the hospital, as compared to 4 hours 30 minutes and 7.6% admitted for younger adults.

Table 1 shows the demographic data, clinical character- istics, and prior health services use of the 3 older adult populations. Patients identified as users of both the ED and the PCCs had the greatest health services use in the year before the visit and were prescribed the most medications. Notably, 40% of all older ED patients were not seen in the health system’s PCCs in the prior year, and 33% were not seen in the system’s primary care or specialty care clinics. Prior studies have identified older adults as dispropor- tionate users of the ED [6]; however, this is the first to put the use of emergency services by Geriatric patients in the context of use of primary care services. Access to regular primary care is considered an important indicator of quality health care systems [7]. Our investigation found that many older adults using this urban ED do not receive care in this

health care system’s primary or specialty care clinics.

Within our health system, older patients with both ED and PCC visits used the most health services. Similarly, Byrne et al [8] reported that Frequent ED users had more frequent visits to their general practitioner in the prior year. Hansagi et al [9] found that the number of clinic visits significantly increased with increasing frequency of ED visits.

In conclusion, the ED serves as a major contributor to the health care of the elderly within our health care system. Additional study is needed to clarify the proportion of older urban, public ED patients who lack Primary care access and elucidate the extent to which patients present to the ED because of a lack of primary care.

References

1. Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2000 summary. Adv Data 2001;328:1 - 32.
2. Hall MJ, DeFrances CJ. 2001 National Hospital Discharge Survey. Adv

Data 2003;332:1 - 20.

1. McDonald CJ, Overhage JM, Tierney WM, et al. The Regenstrief Medical Record System: a quarter century experience. Int J Med Inf 1999;54:225 - 53.
2. Strange GR, Chen EH. Use of emergency departments by elder patients: a five-year follow-up study. Acad Emerg Med 1998;5:1157 - 62.
3. Starfield B. Primary care: concept, evaluation, and policy. New York (NY)7 Oxford Univ. Press; 1992.
4. Byrne M, Murphy AW, Plunkett PK, et al. Frequent attenders to an emergency department: a study of primary Health care use, medical profile, and psychosocial characteristics. Ann Emerg Med 2003;41: 309 - 18.
5. Hansagi H, Olsson M, Sjoberg S, et al. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med 2001;37:561 - 7.

Kevin M. Terrell DO, MS Carey D. Chisholm MD Roland B. McGrath MD

Department of Emergency Medicine Indiana University School of Medicine Indianapolis, IN 46202, USA

E-mail address: [email protected]

Anthony J. Perkins MS Amna B. Buttar MD, MS Christopher M. Callahan MD Regenstrief Institute, Inc

Indiana University School of Medicine Indianapolis, IN 46202, USA

Indiana University Center for Aging Research Indiana University School of Medicine Indianapolis, IN 46202, USA

Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis, IN 46202, USA

1. McCaig LF, Burt CW. National hospital ambulatory medical care survey:

2001 emergency department summary. Adv Data 2002;335:1 - 36.

1. Burt CW, McCaig LF. Trends in hospital emergency department utilization: United States, 1992-99. Vital Health Stat 13 2003;150:1 - 34.

These data were presented via poster presentation by Kevin M. Terrell, DO, at The Gerontological Society of America Annual Meeting, San Diego, Calif, on November 23, 2003.