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Risk factors for frequent emergency department visits of veterans home residents in Northern Taiwan
Journal of Clinical Gerontology & Geriatrics 3 (2012) 118e121
Contents lists available at SciVerse ScienceDirect
Journal of Clinical Gerontology & Geriatrics journal homepage: www.e-jcgg.com
Original article
Risk factors for frequent emergency department visits of veterans home residents in Northern Taiwan Cheng-Hung Chiang, MD a, Ming-Yueh Chou, MD b, c, d, Shang-Lin Chou, MD e, f, Chih-Kuang Liang, MD c, d, g, Liang-Kung Chen, MD d, h, *, David Hung-Tsang Yen, MD, PhD f, i, Ming-Shium Tu, MD b a
Division of Internal Medicine, Kaohsiung Veterans General Hospital, Pingtung Branch, Pingtung County, Taiwan Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan Geriatric Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan d National Yang-Ming University, School of Medicine, Taipei, Taiwan e Department of Emergency Medicine, Fooyin University Hospital, Pingtung County, Taiwan f Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan g Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan h Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan i Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 June 2011 Received in revised form 10 August 2011 Accepted 30 August 2011
Purpose: The purpose of this study was to evaluate risk factors for frequent emergency department (ED) visits among older Chinese men living in a veterans home in northern Taiwan Methods: In 2006, all residents of Banciao Veterans Home were invited for study. Minimum Data Set Nursing Home 2.1 Chinese version, Chinese version of Geriatric Depression Scale (GDS) short form, minimental status examinations (MMSE), and Charlson Comorbidity Index (CCI) were used for study. ED records of all study participants were obtained from Taipei Veterans General Hospital, and frequent ED visitors were defined as who visited ED for three times or more in 1 year. Results: Overall, 609 residents (mean age ¼ 80.9 5.3 years, all men) were enrolled, and 169 (27.8%) of them visited the ED for at least once. Among all participants, 30 (4.9%) were frequent ED visitors. Frequent ED visitors were significantly older, disabled, cognitively impaired, depressed, urinary incontinent, having poorer social engagement score, and higher Charlson’s comorbidity index (CCI). Adjustments for age, activities of daily living, depression, cognitive impairment (adjusted odds ratio: 3.19; 95% confidence interval: 1.37e7.46, p ¼ 0.004) and higher CCI (adjusted odds ratio: 1.69; 95% confidence interval: 1.20e2.39, p ¼ 0.003) were independent risk factors for frequent ED visits. Conclusion: The cumulative incidence of ED visit was 51 visits per 100 person-years, and the prevalence of frequent ED visitors was 4.9% among older veterans living in a Veterans Home. Cognitive impairment and higher Charlson’s comorbidity index were independent risk factors for frequent ED visitors. Further study is needed to explore the unmet health-care needs for frequent ED visitors in the veterans home. Copyright Ó 2012, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: Elderly Emergency department Frequent visits Long-term care
1. Introduction Population aging is a global phenomenon that affects both developing and developed countries, and Taiwan is no exception. Taiwan was estimated to become the fastest aging country in the world, and the percentage of elderly population in Taiwan will be
* Corresponding author. Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Number 201, Section 2, Shih-Pai Road, Taipei, Taiwan. E-mail address: [email protected] (L.-K. Chen).
doubled from 2010 to 2025.1 The escalation of elderly population may cause various challenges to health-care systems, which also includes emergency department (ED) services. In Taiwan, the ED was overcrowded nationwide,2 and frequent ED visitors may aggravate this situation. It was generally agreed that older people were more prone to visit the ED by ambulance with high-priority triage, longer ED stay, more costly care, and are more likely to be hospitalized.3e5 Although the ED has become the main entry for acute medical services for older people,6,7 one-half of ED physicians reported that they lack proper knowledge and skills to manage older patients and often felt uneasy to treat older patients.8 Further,
2210-8335/$ e see front matter Copyright Ó 2012, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.jcgg.2012.09.001
C.-H. Chiang et al. / Journal of Clinical Gerontology & Geriatrics 3 (2012) 118e121
frequent ED visits were associated with higher medical expenditures, and the lack of proper access to health care,9 which may result in a vicious cycle in health care services. Frequent ED visitors were also heavy users of other health-care services and the overall mortality rate was high, suggesting that they were poorer in health status and resources of care than others.10 Common features of frequent ED visits included men, African Americans, presence of psychosocial and economic problems, and alcohol-dependence in previous studeis,11e13 but little was known regarding to the risk factors of frequent ED visits among older people in Taiwan. In Taiwan, older veterans living in the veteran homes were often functionally dependent with multiple medical care needs.14 For veteran home residents, they would be sent to nearby veterans hospitals for further medical care if ED care was needed. In northern Taiwan, residents of veteran homes were sent to Taipei Veterans General Hospital, a tertiary medical center, for ED services.15 Therefore, the main purpose of this study was to explore the characteristics of frequent ED visitors among residents in a veteran home to identify those with high risk of frequent ED visits. 2. Materials and methods 2.1. Participants From January to December of 2006, all residents living Banciao Veterans Home were invited for study and participants were enrolled if they agreed to participate. Those who had altered consciousness, severe hearing impairment, and communication difficulties were excluded for study. Minimum Data Set (MDS) Nursing Home 2.1 Chinese version was systematically implemented for all participants. Besides, well-trained research nurses periodically visited participants and completed following questionnaire: Chinese version Geriatric Depression Scale (GDS) short form, Chinese version of mini-mental status examinations (MMSE), and Charlson Comorbidity Index. In addition, medical records of participants visiting the ED of Taipei Veterans General Hospital were collected. Frequent ED visits were defined as those who visited the ED for three times or more in 1 year.16 2.2. Measures 2.2.1. Social engagement Social engagement was evaluated by MDS social engagement score, which has been reported as the surrogate of quality of life.17 The summation of social engagement score was between zero and six, and the score of six indicated normal social interaction, and a lower score suggested poorer social engagement. 2.2.2. Physical function In this study, physical function was evaluated by the MDS Resource Utilization Group Activities of Daily Living (RUG ADL) score, which consisted of eating, bed mobility, transferring and toileting.18 The summation of RUG ADL score (range, 4e18) was used to evaluate physical function of the resident, and the lower MDS RUG ADL score was considered less physical dependence. 2.2.3. Depression GDS short form has been validated as a reliable depression screening tool,19 a cut-off of six or more was considered depression. 2.2.4. Cognitive function The Chinese version of MMSE was used to assess cognitive function for all participants, which included items of temporal orientation, spatial orientation, immediate memory, attention/
119
concentration, delayed recall, naming, verbal repetition, verbal comprehension, writing, reading a sentence, and constructional praxis.20 The score of <24 was considered cognitive impairment. 2.2.5. Comorbidity The Charlson Comorbidity Index (CCI) was used to evaluate comorbidity in this study, which consisted of 19 categories of disease entities, and each disease entity had an associated weight. The overall CCI score reflected the cumulative increased likelihood of 1-year mortality.21 2.3. Statistical analysis All continuous variables were expressed as mean standard deviation, and categorical data were expressed as frequency. Analyses of categorical variables were performed by Chi-square or Fisher’s exact test when appropriate. The independent Student t-test was used to compare continuous variables. The Statistical Package for the Social Sciences (SPSS) version 17.0 software (SPSS, Chicago, IL, USA) was used to perform all statistical analyses. For all tests, a two-tailed p < 0.05 was considered statistically significant. 3. Results In total, 609 residents (mean age: 80.9 5.3 years, all males) were enrolled for study. Among them, 169 residents (27.8%) had visited the ED at least once during the study period and 30 residents (4.9%) were frequent ED visitors by definition. The cumulative incidence of ED visits in this study was 51 visits per 100 person-years. Univariate analysis showed that frequent ED visitors were significantly older than non-frequent ED visitors (82.9 5.6 vs. 80.8 5.3 years, p ¼ 0.032). In addition, frequent ED visitors were having higher CCI (1.5 1.0 vs. 0.7 0.9, p ¼ 0.001), MDS RUG ADL score (5.9 3.1 vs. 4.3 1.5, p < 0.001), prevalence of depression (20% vs. 8%, p ¼ 0.023), cognitive impairment (53.3% vs. 16.8%, p < 0.001), urinary incontinence (23.3% vs. 9.2%, p ¼ 0.012), and lower MDS social engagement score (0.9 1.2 vs. 1.6 1.3, p ¼ 0.008; Table 1). Table 2 shows the independent risk factors for frequent ED visitors by using multivariate logistic regression, which found that cognitive impairment [adjusted odds ratio (OR): 3.19; 95% confidence interval (CI): 1.37e7.46, p ¼ 0.004] and higher CCI (adjusted OR: 1.69; 95% CI: 1.20e2.39, p ¼ 0.003) were both independent risk factors for frequent ED visits. 4. Discussion Taiwan became the aging country (percentage of elderly people exceeding 7% of total population) in 1993, and was estimated to Table 1 Univariate analysis of participants’ characteristics and their frequency of ED visits in 1 year. Characteristics
ED visit three times (N ¼ 30)
ED visit < three times (N ¼ 579)
p value
Age (yr) Charlson comorbidity index MDS RUG ADL score MDS social engagement score Depressiona Cognitive impairmentb Urinary incontinence
82.9 5.6 1.5 1.0 5.9 3.1 0.9 1.2 20.0% 53.3% 23.3%
80.8 5.3 0.7 0.9 4.3 1.5 1.6 1.3 8.0% 16.8% 9.2%
0.032 0.001 <0.001 0.008 0.023 <0.001 0.012
ED ¼ emergency department; MDS RUG ADL score ¼ minimum data set resource utilization group activity of daily living score. a Depression was defined as 15-items geriatric depression scale score 5. b Cognitive impairment was defined as minimal-mental status examination 24.
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Table 2 Results of multivariate logistic regression model of factors related to frequent ED visits.
Cognitive impairment Charlson comorbidity index
Adjusted odds ratio
95% confidence interval
p value
3.19 1.69
1.37e7.46 1.20e2.39
0.004 0.003
ED ¼ emergency department.
become the aged country (elderly population exceeding 14% of total population) by 2019, which made Taiwan the fastest aging country in the world.1 The escalating elderly population in Taiwan may result in various challenges to the health-care systems.22,23 In Taiwan, EDs were overcrowded across the country,2 and frequent ED visitors may aggravate burden of ED services and medical expenditures.9,10 In this study, the cumulative incidence of ED visits was 51 visits per 100 person-years, which was lower than that were previously reported (110e131.4 visits per 100 person-years).24,25 The lower incidence of ED utilization in this study may be related to the active role of primary care physicians as ED service gatekeepers. The reduction of inappropriate or unnecessary ED visits by active primary care physicians was also supported by several previous studies.26e29 In this study, 4.9% of the veteran home residents were frequent ED visitors, which was similar to the previous report (4.5%e8%).30 The definition of frequent ED visitors varied extensively from two visits to 12 visits per year.30 It has been reported that the need for a small number of ED visits within 1 year (e.g., an accident or a clear medical emergency) may be considered a reasonable health care need, but those who had three or more ED visits were more likely to become dependent on EDs as the sole source of medical care.21 Moreover, Ruger et al9 reported that patients with three or more ED visits were more likely to be hospitalized than those who visited only once or twice. The prevalence of dementia in people aged over 85 years may reach 30%,31,32 but the prevalence of cognitive deficits in veterans home was 18.6%, which was associated with lower educational status, older age and poorer functional status.33 In this study, cognitive impairment was an independent risk factor of frequent ED visits after adjustment of age, depression, and functional status. Patients with cognitive impairment were also heavy users of ED and other health care services,34 and early identification of cognitive impairment was of great importance to avoid unnecessary medical care utilization. On the other hand, higher CCI was also significantly associated with frequent ED visits. Higher CCI and the presence of more geriatric care problems both predicted 12month mortality in this setting,14 so a proper health management is needed to improve the quality of care. There are several limitations in this study. First, the demographic characteristics of all study participants were very homogenous because of the admission criteria of veteran homes, which limited the extrapolation of study results. Second, main reasons of ED visits for all study participants remained unexplored, so we were unclear about the major health concerns of frequent ED visitors. Third, the impact of frequent ED visits on long-term health care outcomes remained unclear due to the short study period. Despite the aforementioned limitations, the main strength of this study was that we identified risk factors of frequent ED visits among older veterans in Taiwan. Older veterans were considered heavy users of medical care resources due to their advanced age, disabilities, and lack of family support in Taiwan.35,36 Therefore, results of this study may help to identify those who were prone to be frequent ED visitors and to implement certain intervention programs to improve the quality of care. In conclusion, the cumulative incidence of ED visit in this study was 51 per 100 person-years and 4.9% of older veterans
living in the veteran care homes were frequent ED visitors. Cognitive impairment and higher Charlson’s comorbidity index were both independent risk factors for frequent ED visits. Further study is needed to evaluate main health care problems of frequent ED visits and the effectiveness of intervention programs to improve quality of care. References 1. Lin MH, Chou MY, Liang CK, Peng LN, Chen LK. Population aging and its impacts: strategies of the health-care system in Taipei. Ageing Res Rev 2010;9(Suppl. 1):S23e7. 2. Shih FY, Ma MH, Chen SC, Wang HP, Fang CC, Shyu RS, et al. ED overcrowding in Taiwan: facts and strategies. Am J Emerg Med 1999;17:198e202. 3. Hu SC, Yen D, Yu YC, Kao WF, Wang LM. Elderly use of the ED in an Asian metropolis. Am J Emerg Med 1999;17:95e9. 4. Huang JA, Weng RH, Tsai WC, Hu WH, Yang DY. Analysis of emergency department utilization by elderly patients under National Health Insurance. Kaohsiung J Med Sci 2003;19:113e20. 5. Wong CH, Wang TL, Chang H, Lee YK. Age-related emergency department utilization: a clue of patient demography in disaster medicine. Ann Disaster Med 2003;1:56e69. 6. Strange GR, Chen EH, Sanders AB. Use of emergency departments by elderly patients: projections from a multicenter data base. Ann Emerg Med 1992;21: 819e24. 7. Wofford JL, Schwartz E, Byrum JE. The role of emergency services in health care for the elderly: a review. J Emerg Med 1993;11:317e26. 8. Schumacher JG, Deimling GT, Meldon S, Woolard B. Older adults in the emergency department: predicting physicians’ burden levels. J Emerg Med 2006;30:455e60. 9. Ruger JP, Richter CJ, Spitznagel EL, Lewis LM. Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy. Acad Emerg Med 2004;11:1311e7. 10. Hansagi H, Olsson M, Sjöberg S, Tomson Y, Göransson S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med 2001;37:561e7. 11. Purdie FR, Honigman B, Rosen P. The chronic emergency department patient. Ann Emerg Med 1981;10:298e301. 12. Kne T, Young R, Spillane L. Frequent ED users: patterns of use over time. Am J Emerg Med 1998;16:648e52. 13. Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad Emerg Med 2000;7:637e46. 14. Chen LK, Peng LN, Lin MH, Lai HY, Hwang SJ, Lan CF. Predicting mortality of older residents in long-term care facilities: comorbidity or care problems? J Am Med Dir Assoc 2010;11:567e71. 15. Chou MY, Chou SL, Tzeng YM, Chen LK, Oliver D, Yen DH, et al. Emergency department (ED) utilization of oldest old men in a veterans care home in Taiwan. Arch Gerontol Geriatr 2009;48:258e62. 16. Zuckerman S, Shen YC. Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter? Med Care 2004;42:176e82. 17. Vincent Mor V, Branco K, Fleishman J, Hawes C, Phillips C, Morris J , et al. The structure of social engagement among nursing home residents. J Gerontol B Psychol Sci Soc Sci 1995;50:P1e8. 18. Fries BE, Schneider DP, Foley WJ, Gavazzi M, Burke R, Cornelius E. Refining a case mix measure for nursing homes: Resource Utilization Groups (RUG-III). Med Care 1994;32:668e85. 19. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5:165e73. 20. Folstein MF, Folstein SE, McHugh PR. Mini-mental status: a pratical method for grading the cognitive state of patients for the clinical use. J Psychiatr Res 1975;12:189e98. 21. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373e83. 22. Chen CY. Meeting the challenges of eldercare in Taiwan’s aging society. J Clin Gerontol Geriatr 2010;1:2e4. 23. Chen LK. A new era of research on clinical gerontology and geriatrics in Asia. J Clin Gerontol Geriatr 2010;1:1. 24. Ackermann RJ, Kemle KA, Vogel RL, Griffin Jr RC. Emergency department use by nursing home residents. Ann Emerg Med 1998;31:749e57. 25. Carter MW, Gupta S. Characteristics and outcomes of injury-related ED visits among older adults. Am J Emerg Med 2008;26:296e303. 26. Engelhardt JB, Toseland RW, O’Donnell JC, Richie JT, Jue D, Banks S. The effectiveness and efficiency of outpatient geriatric evaluation and management. J Am Geriatr Soc 1996;44:847e56. 27. Toseland RW, O’Donnell JC, Engelhardt JB, Richie J, Jue D, Banks SM. Outpatient geriatric evaluation and management: is there an investment effect? Gerontologist 1997;37:324e32. 28. Keeler EB, Robalino DA, Frank JC, Hirsch SH, Maly RC, Reuben DB. Cost-effectiveness of outpatient geriatric assessment with an intervention to increase adherence. Med Care 1999;37:1199e206.
C.-H. Chiang et al. / Journal of Clinical Gerontology & Geriatrics 3 (2012) 118e121 29. Phibbs CS, Holty JE, Goldstein MK, Garber AM, Wang Y, Feussner JR, et al. The effect of geriatrics evaluation and management on nursing home use and health care costs: results from a randomized trial. Med Care 2006;44: 91e5. 30. LaCalle E, Rabin E. Frequent users of emergency departments: the myths, the data, and the policy implications. Ann Emerg Med 2010;56: 42e8. 31. Liu CK. The epidemiology of dementia in Taiwan. Acta Neurol Taiwan 2006;15: 51e2. 32. Liu HC, Wang SJ, Fuh JL, Liu CY, Lin KP, Lin CH, et al. The Kinmen Neurological Disorders Survey (KINDS): a study of a Chinese population. Neuroepidemiology 1997;16:60e8.
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33. Lin CS, Chen LK, Hwang SJ, Lan CF, Tang YJ, Liu PH. Cognitive impairment among institutionalized elderly in a veteran home. Taiwan Geriatr Gerontol 2007;2:243e50. 34. Richards KM, Shepherd MD, Crismon ML, Snyder EH, Jermain DM. Medical services utilization and charge comparisons between elderly patients with and without Alzheimer’s disease in a managed care organization. Clin Ther 2000;22: 775e91. 35. Lin YT, Hwang SJ, Chen LK, Chen TJ, Hwang IH. Ambulatory health care utilization of the older people under the National Health Insurance in Taiwan. J Clin Gerontol Geriatr 2011;2:53e7. 36. Hsiao FY. Improving care for older people: where can we start? J Clin Gerontol Geriatr 2011;2:33e4.
Contents lists available at SciVerse ScienceDirect
Journal of Clinical Gerontology & Geriatrics journal homepage: www.e-jcgg.com
Original article
Risk factors for frequent emergency department visits of veterans home residents in Northern Taiwan Cheng-Hung Chiang, MD a, Ming-Yueh Chou, MD b, c, d, Shang-Lin Chou, MD e, f, Chih-Kuang Liang, MD c, d, g, Liang-Kung Chen, MD d, h, *, David Hung-Tsang Yen, MD, PhD f, i, Ming-Shium Tu, MD b a
Division of Internal Medicine, Kaohsiung Veterans General Hospital, Pingtung Branch, Pingtung County, Taiwan Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan Geriatric Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan d National Yang-Ming University, School of Medicine, Taipei, Taiwan e Department of Emergency Medicine, Fooyin University Hospital, Pingtung County, Taiwan f Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan g Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan h Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan i Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 June 2011 Received in revised form 10 August 2011 Accepted 30 August 2011
Purpose: The purpose of this study was to evaluate risk factors for frequent emergency department (ED) visits among older Chinese men living in a veterans home in northern Taiwan Methods: In 2006, all residents of Banciao Veterans Home were invited for study. Minimum Data Set Nursing Home 2.1 Chinese version, Chinese version of Geriatric Depression Scale (GDS) short form, minimental status examinations (MMSE), and Charlson Comorbidity Index (CCI) were used for study. ED records of all study participants were obtained from Taipei Veterans General Hospital, and frequent ED visitors were defined as who visited ED for three times or more in 1 year. Results: Overall, 609 residents (mean age ¼ 80.9 5.3 years, all men) were enrolled, and 169 (27.8%) of them visited the ED for at least once. Among all participants, 30 (4.9%) were frequent ED visitors. Frequent ED visitors were significantly older, disabled, cognitively impaired, depressed, urinary incontinent, having poorer social engagement score, and higher Charlson’s comorbidity index (CCI). Adjustments for age, activities of daily living, depression, cognitive impairment (adjusted odds ratio: 3.19; 95% confidence interval: 1.37e7.46, p ¼ 0.004) and higher CCI (adjusted odds ratio: 1.69; 95% confidence interval: 1.20e2.39, p ¼ 0.003) were independent risk factors for frequent ED visits. Conclusion: The cumulative incidence of ED visit was 51 visits per 100 person-years, and the prevalence of frequent ED visitors was 4.9% among older veterans living in a Veterans Home. Cognitive impairment and higher Charlson’s comorbidity index were independent risk factors for frequent ED visitors. Further study is needed to explore the unmet health-care needs for frequent ED visitors in the veterans home. Copyright Ó 2012, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: Elderly Emergency department Frequent visits Long-term care
1. Introduction Population aging is a global phenomenon that affects both developing and developed countries, and Taiwan is no exception. Taiwan was estimated to become the fastest aging country in the world, and the percentage of elderly population in Taiwan will be
* Corresponding author. Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Number 201, Section 2, Shih-Pai Road, Taipei, Taiwan. E-mail address: [email protected] (L.-K. Chen).
doubled from 2010 to 2025.1 The escalation of elderly population may cause various challenges to health-care systems, which also includes emergency department (ED) services. In Taiwan, the ED was overcrowded nationwide,2 and frequent ED visitors may aggravate this situation. It was generally agreed that older people were more prone to visit the ED by ambulance with high-priority triage, longer ED stay, more costly care, and are more likely to be hospitalized.3e5 Although the ED has become the main entry for acute medical services for older people,6,7 one-half of ED physicians reported that they lack proper knowledge and skills to manage older patients and often felt uneasy to treat older patients.8 Further,
2210-8335/$ e see front matter Copyright Ó 2012, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.jcgg.2012.09.001
C.-H. Chiang et al. / Journal of Clinical Gerontology & Geriatrics 3 (2012) 118e121
frequent ED visits were associated with higher medical expenditures, and the lack of proper access to health care,9 which may result in a vicious cycle in health care services. Frequent ED visitors were also heavy users of other health-care services and the overall mortality rate was high, suggesting that they were poorer in health status and resources of care than others.10 Common features of frequent ED visits included men, African Americans, presence of psychosocial and economic problems, and alcohol-dependence in previous studeis,11e13 but little was known regarding to the risk factors of frequent ED visits among older people in Taiwan. In Taiwan, older veterans living in the veteran homes were often functionally dependent with multiple medical care needs.14 For veteran home residents, they would be sent to nearby veterans hospitals for further medical care if ED care was needed. In northern Taiwan, residents of veteran homes were sent to Taipei Veterans General Hospital, a tertiary medical center, for ED services.15 Therefore, the main purpose of this study was to explore the characteristics of frequent ED visitors among residents in a veteran home to identify those with high risk of frequent ED visits. 2. Materials and methods 2.1. Participants From January to December of 2006, all residents living Banciao Veterans Home were invited for study and participants were enrolled if they agreed to participate. Those who had altered consciousness, severe hearing impairment, and communication difficulties were excluded for study. Minimum Data Set (MDS) Nursing Home 2.1 Chinese version was systematically implemented for all participants. Besides, well-trained research nurses periodically visited participants and completed following questionnaire: Chinese version Geriatric Depression Scale (GDS) short form, Chinese version of mini-mental status examinations (MMSE), and Charlson Comorbidity Index. In addition, medical records of participants visiting the ED of Taipei Veterans General Hospital were collected. Frequent ED visits were defined as those who visited the ED for three times or more in 1 year.16 2.2. Measures 2.2.1. Social engagement Social engagement was evaluated by MDS social engagement score, which has been reported as the surrogate of quality of life.17 The summation of social engagement score was between zero and six, and the score of six indicated normal social interaction, and a lower score suggested poorer social engagement. 2.2.2. Physical function In this study, physical function was evaluated by the MDS Resource Utilization Group Activities of Daily Living (RUG ADL) score, which consisted of eating, bed mobility, transferring and toileting.18 The summation of RUG ADL score (range, 4e18) was used to evaluate physical function of the resident, and the lower MDS RUG ADL score was considered less physical dependence. 2.2.3. Depression GDS short form has been validated as a reliable depression screening tool,19 a cut-off of six or more was considered depression. 2.2.4. Cognitive function The Chinese version of MMSE was used to assess cognitive function for all participants, which included items of temporal orientation, spatial orientation, immediate memory, attention/
119
concentration, delayed recall, naming, verbal repetition, verbal comprehension, writing, reading a sentence, and constructional praxis.20 The score of <24 was considered cognitive impairment. 2.2.5. Comorbidity The Charlson Comorbidity Index (CCI) was used to evaluate comorbidity in this study, which consisted of 19 categories of disease entities, and each disease entity had an associated weight. The overall CCI score reflected the cumulative increased likelihood of 1-year mortality.21 2.3. Statistical analysis All continuous variables were expressed as mean standard deviation, and categorical data were expressed as frequency. Analyses of categorical variables were performed by Chi-square or Fisher’s exact test when appropriate. The independent Student t-test was used to compare continuous variables. The Statistical Package for the Social Sciences (SPSS) version 17.0 software (SPSS, Chicago, IL, USA) was used to perform all statistical analyses. For all tests, a two-tailed p < 0.05 was considered statistically significant. 3. Results In total, 609 residents (mean age: 80.9 5.3 years, all males) were enrolled for study. Among them, 169 residents (27.8%) had visited the ED at least once during the study period and 30 residents (4.9%) were frequent ED visitors by definition. The cumulative incidence of ED visits in this study was 51 visits per 100 person-years. Univariate analysis showed that frequent ED visitors were significantly older than non-frequent ED visitors (82.9 5.6 vs. 80.8 5.3 years, p ¼ 0.032). In addition, frequent ED visitors were having higher CCI (1.5 1.0 vs. 0.7 0.9, p ¼ 0.001), MDS RUG ADL score (5.9 3.1 vs. 4.3 1.5, p < 0.001), prevalence of depression (20% vs. 8%, p ¼ 0.023), cognitive impairment (53.3% vs. 16.8%, p < 0.001), urinary incontinence (23.3% vs. 9.2%, p ¼ 0.012), and lower MDS social engagement score (0.9 1.2 vs. 1.6 1.3, p ¼ 0.008; Table 1). Table 2 shows the independent risk factors for frequent ED visitors by using multivariate logistic regression, which found that cognitive impairment [adjusted odds ratio (OR): 3.19; 95% confidence interval (CI): 1.37e7.46, p ¼ 0.004] and higher CCI (adjusted OR: 1.69; 95% CI: 1.20e2.39, p ¼ 0.003) were both independent risk factors for frequent ED visits. 4. Discussion Taiwan became the aging country (percentage of elderly people exceeding 7% of total population) in 1993, and was estimated to Table 1 Univariate analysis of participants’ characteristics and their frequency of ED visits in 1 year. Characteristics
ED visit three times (N ¼ 30)
ED visit < three times (N ¼ 579)
p value
Age (yr) Charlson comorbidity index MDS RUG ADL score MDS social engagement score Depressiona Cognitive impairmentb Urinary incontinence
82.9 5.6 1.5 1.0 5.9 3.1 0.9 1.2 20.0% 53.3% 23.3%
80.8 5.3 0.7 0.9 4.3 1.5 1.6 1.3 8.0% 16.8% 9.2%
0.032 0.001 <0.001 0.008 0.023 <0.001 0.012
ED ¼ emergency department; MDS RUG ADL score ¼ minimum data set resource utilization group activity of daily living score. a Depression was defined as 15-items geriatric depression scale score 5. b Cognitive impairment was defined as minimal-mental status examination 24.
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C.-H. Chiang et al. / Journal of Clinical Gerontology & Geriatrics 3 (2012) 118e121
Table 2 Results of multivariate logistic regression model of factors related to frequent ED visits.
Cognitive impairment Charlson comorbidity index
Adjusted odds ratio
95% confidence interval
p value
3.19 1.69
1.37e7.46 1.20e2.39
0.004 0.003
ED ¼ emergency department.
become the aged country (elderly population exceeding 14% of total population) by 2019, which made Taiwan the fastest aging country in the world.1 The escalating elderly population in Taiwan may result in various challenges to the health-care systems.22,23 In Taiwan, EDs were overcrowded across the country,2 and frequent ED visitors may aggravate burden of ED services and medical expenditures.9,10 In this study, the cumulative incidence of ED visits was 51 visits per 100 person-years, which was lower than that were previously reported (110e131.4 visits per 100 person-years).24,25 The lower incidence of ED utilization in this study may be related to the active role of primary care physicians as ED service gatekeepers. The reduction of inappropriate or unnecessary ED visits by active primary care physicians was also supported by several previous studies.26e29 In this study, 4.9% of the veteran home residents were frequent ED visitors, which was similar to the previous report (4.5%e8%).30 The definition of frequent ED visitors varied extensively from two visits to 12 visits per year.30 It has been reported that the need for a small number of ED visits within 1 year (e.g., an accident or a clear medical emergency) may be considered a reasonable health care need, but those who had three or more ED visits were more likely to become dependent on EDs as the sole source of medical care.21 Moreover, Ruger et al9 reported that patients with three or more ED visits were more likely to be hospitalized than those who visited only once or twice. The prevalence of dementia in people aged over 85 years may reach 30%,31,32 but the prevalence of cognitive deficits in veterans home was 18.6%, which was associated with lower educational status, older age and poorer functional status.33 In this study, cognitive impairment was an independent risk factor of frequent ED visits after adjustment of age, depression, and functional status. Patients with cognitive impairment were also heavy users of ED and other health care services,34 and early identification of cognitive impairment was of great importance to avoid unnecessary medical care utilization. On the other hand, higher CCI was also significantly associated with frequent ED visits. Higher CCI and the presence of more geriatric care problems both predicted 12month mortality in this setting,14 so a proper health management is needed to improve the quality of care. There are several limitations in this study. First, the demographic characteristics of all study participants were very homogenous because of the admission criteria of veteran homes, which limited the extrapolation of study results. Second, main reasons of ED visits for all study participants remained unexplored, so we were unclear about the major health concerns of frequent ED visitors. Third, the impact of frequent ED visits on long-term health care outcomes remained unclear due to the short study period. Despite the aforementioned limitations, the main strength of this study was that we identified risk factors of frequent ED visits among older veterans in Taiwan. Older veterans were considered heavy users of medical care resources due to their advanced age, disabilities, and lack of family support in Taiwan.35,36 Therefore, results of this study may help to identify those who were prone to be frequent ED visitors and to implement certain intervention programs to improve the quality of care. In conclusion, the cumulative incidence of ED visit in this study was 51 per 100 person-years and 4.9% of older veterans
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