Comorbidities Common in Older ‘Frequent Fliers’ in the ED

Frequency of emergency department (ED) visits for older adults was strongly predicted by their number of comorbidities, researchers said.

In an analysis of a geriatric population (ages ≥65), the presence of three or more clinical conditions was tied to an over seven times higher odds of being a “frequent” ED user (OR 7.2, 95% CI 7.0-7.5), reported Edward M. Castillo, PhD, MPH, of University of California San Diego, and colleagues.

Older adults who visited the ED from six to 20 times in 1 year were considered to be frequent users, compared with less frequent users who clocked in less than six visits a year, the group explained in the Annals of Emergency Medicine.

Among 17 different clinical conditions included in the analysis, diabetes without complications was the most common comorbidity among frequent geriatric patients in the ED:

• Diabetes: 25.8% of frequent users
• Chronic pulmonary disease: 21.5%
• Renal disease: 19.1%
• Congestive heart failure: 16%
• Peripheral vascular disease: 15.1%

These were the most common comorbidities seen for geriatric patients, regardless if they were frequent visitors of the ED or not, according to the authors.

In order to reduce diabetes-related complications in older adults, the American Diabetes Association 2019 clinical guidelines recommends individualized glycemic targets for patients ages >65, with an upper target of 7.5% for those with few comorbidities and a looser upper target of 8.0%-8.5% for those with poorer health. The guidelines also place high importance on treatment of comorbidities to reduce risk of hospitalization, particularly in regards to hypertension and other cardiovascular risk factors, as well as screening for functional impairment.

In addition to having relatively many comorbidities, pain-related diagnoses (OR 5.5, 95% CI 5.4-5.6) and injury-related visit (OR 3.8, 95% CI 3.8-3.9) were two other factors strongly associated with being a frequent ED visitor as a patient.

Other factors linked to more frequent ED visits were a substance abuse problem (OR 1.86, 95% CI 1.82-1.90) and a psychiatric diagnosis (OR 2.69, 95% CI 2.62-2.73). Patients who frequented the ED more often were also more likely to be admitted or transferred to the hospital compared with less frequent users (85.5% vs 44.6%), and were also more likely to discontinue care (7.8% vs 1.7%).

“Efforts to improve care for vulnerable older Americans should focus on enhancing delivery and decreasing utilization,” Castillo said in a statement. “Older patients are more likely to have multiple chronic conditions which makes emergency care increasingly complex. A better understanding of older patients opens the door for interventions in and beyond the emergency department.”

“This study shows that there are opportunities for both cost savings and more targeted interventions to help improve outcomes for seniors in the emergency department, where they often experience the health care system,” added co-author Kelly Ko, PhD, of the West Health Institute in San Diego, in the statement.

The California-based analysis of 326 acute care hospitals included data on nearly 1.3 million geriatric patients who visited an ED in 2014, totalling nearly 2.8 million visits. Less frequent ED users represented 79% of all geriatric patient visits. However, one-fifth of these visits were by frequent users, who accounted for less than 6% of geriatric patient population. “Super users” — those who visited the ED >20 times in a year — were 0.1% of geriatric ED users and accounted for 1.3% of all ED visits.

Study limitations included lack of information on care the patients received beyond the ED, such as primary and prevention care.

For future research, the authors suggested studies should aim to “further define the population of geriatric frequent ED users and their specific health issues to better understand their healthcare needs to better serve this vulnerable and complex population.”