JMIR Publications

ABSTRACT

Background:

Older adults (65+) often present to the emergency department (ED) with unclear need for hospitalization, leading to potentially harmful and costly care. This underscores the importance of measuring the tradeoff between admission and discharge for these patients in terms of patient outcomes.

Objective:

To measure the relationship between disposition decision and 3-day, 9-day, and 30-day revisits, readmission, and mortality, using causal inference methods that adjust for potential measured and unmeasured confounding.

Methods:

A longitudinal observational study (n = 3591) was conducted using electronic healthcare records from a large tertiary teaching ED hospital between January 1, 2014 and September 27, 2018. The sample consisted of older adult patients with one of six presentations with significant variability in admission: falls, weakness, syncope, UTI, pneumonia, and cellulitis. The exposure under consideration is the ED disposition decision (admission to the hospital or discharge). Nine outcome variables were considered: ED revisits, hospital readmission, and mortality within 3, 9, and 30 days of being discharged from either the hospital for admitted patients or the ED for discharged patients.

Results:

Admission was estimated to significantly decrease the risk of an ED revisit after discharge (30-day window: -6.4%, 95% CI [-7.8, -5.0]), while significantly increasing the risk of hospital readmission (30-day window: 5.8%, 95% CI [5.0, 6.5]) and mortality (30-day window: 1.0%, 95% CI: [0.4, 1.6]). Admission was found to be especially adverse for patients with weakness and pneumonia, and relatively less adverse for older adult patients with falls and syncope.

Conclusions:

Admission may not be the safe option for older adults with gray area presentations, and while revisits and readmissions are commonly used to evaluate quality of care in the ED, their divergence suggests that caution should be used when interpreting either in isolation.