ED Utilization High During Last Months of Life

ACEP News
August 2010

By Damian McNamara 
Elsevier Global Medical News

ORLANDO -- Almost three-quarters of people aged 65 years and older visit emergency departments in their last 6 months of life, including just more than half during their last month, according to a study of 3,224 seniors.

These high utilization rates suggest that emergency department (ED) clinicians should be included in initiatives to improve end-of-life care, such as hospice and better patient-provider communication, Dr. Alexander K. Smith said. "When people come to the ED ... it may be an opportunity to change the trajectory of care," said Dr. Smith of the division of geriatrics at the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center.

0810EDUtilNursing home residents were less likely than were community-dwelling elders to visit an emergency department. During the last month of life, 41% of the former group and 54% of the latter did so, Dr. Smith said at the annual meeting of the American Geriatrics Society.

Use of ED services also varied considerably in the study by hospice enrollment, ethnicity, and whether or not the death was expected, which was ascertained through next-of-kin interviews.

Although "qualitative work" has suggested that the ED is the setting for many patients' and families' end-of-life experiences, the frequency of visits before death has been unknown, Dr. Smith said. To find out, he and his associates created a cohort of elderly decedents using data from the Health and Retirement Study, a nationally representative longitudinal survey. During that study, the eventual decedents had been interviewed every 2 years, and Dr. Smith's team focused on the last response prior to death. The study cohort of 3,224 adults included 22% who were 65-74 years old at the time of death between 1995 and 2006, 40% aged 75-85, and 38% older than 85 years at death. Just more than half, 53%, were women.

Dr. Smith and his colleagues linked the survey participants' names to Medicare utilization data to find how many had visited EDs in their last months of life. They also looked at visit frequency in this group: 33% visited an ED once, 20% two times, 10% three times, 6% four times, and 5% five times or more.

Dr. Smith and his colleagues compared the figure for how many people went to EDs in their last 1 month of life, 51%, with data for an age-, gender-, and race/ethnicity-matched cohort of elders who were alive in 2006. The researchers found that only 2% of these matched elders visited the ED in a 1-month period that year.

One aim of the study was to determine factors associated with ED use by dying elders. For example, hospice care had a major influence, Dr. Smith said. The data showed that 3% of hospice enrollees vs. 56% of seniors not enrolled in hospice care visited an ED during the last month of life.

Race/ethnicity was another factor. The cohort was 80% white, 14% black, 5% Hispanic, and 1% other/unknown. The minorities were more likely to visit the emergency department in their final month: 59% of blacks and 62% of Hispanics did so, but only 49% of whites. With whites as a reference group, the adjusted odds ratio for an ED visit in the last month of life was 1.4 among African Americans and 1.6 among Latinos.

Dr. Smith and his associates also compared ED visits when next of kin expected or didn't expect the person's death: 46% of the elders for whom death was expected visited the ED in the last month of life, while 61% of those with unexpected deaths had gone to EDs in that time frame.

The data also showed that, after ED visits, 88% of the overall cohort were hospitalized, including 37% who were admitted to ICUs. More than half, 54%, died while in the hospital. "It also may be important to assess the subset of patients who did not get hospitalized," Dr. Smith said.

He was asked by a meeting attendee whether his team had tallied end-of-life primary care visits by the elderly cohort. "We did not have data on whether or not they had a primary care physician. But we were able to look at whether they visited the doctor frequently, and it was not associated with ED visits."

A limitation of the study was an inability to discern avoidable and unavoidable ED visits, Dr. Smith said. Responding to another question from a meeting attendee, he added, "Even if we were to avoid some of these ED visits, a number of people would end up dying shortly after leaving the ED. That is why the ED is an important place to concentrate efforts regarding end-of-life care."

Dr. Smith had no relevant financial disclosures.

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