Association between the elderly frequent attender to the emergency department and 30-day mortality: A retrospective study over 10 years

doi:10.5847/wjem.j.1920-8642.2018.01.003

Abstract

Abstract:

BACKGROUND: To determine if elderly frequent attenders are associated with increased 30-day mortality, assess resource utilization by the elderly frequent attenders and identify associated characteristics that contribute to mortality.
METHODS: Retrospective observational study of electronic clinical records of all emergency department (ED) visits over a 10-year period to an urban tertiary general hospital in Singapore. Patients aged 65 years and older, with 3 or more visits within a calendar year were identified. Outcomes measured include 30-day mortality, admission rate, admission diagnosis and duration spent at ED. Chi-square-tests were used to assess categorical factors and Student t-test was used to assess continuous variables on their association with being a frequent attender. Univariate and multivariate logistic regressions were conducted on all significant independent factors on to the outcome variable (30-day mortality), to determine factor independent odds ratios of being a frequent attender.
RESULTS: 1.381 million attendance records were analyzed. Elderly patients accounted for 25.5% of all attendances, of which 31.3% are frequent attenders. Their 30-day mortality rate increased from 4.0% in the first visit, to 8.8% in the third visit, peaking at 10.2% in the sixth visit. Factors associated with mortality include patients with neoplasms, ambulance utilization, male gender and having attended the ED the previous year.
CONCLUSION: Elderly attenders have a higher 30-day mortality risk compared to the overall ED population, with mortality risk more marked for frequent attenders. This study illustrates the importance and need for interventions to address frequent ED visits by the elderly, especially in an aging society.

Key words: Frequent attenders, Elderly, Emergency department, Mortality

Yuzeng Shen, Yee Chien Tay, Edward Wee Kwan Teo, Nan Liu, Shao Wei Lam, Marcus Eng Hock Ong. Association between the elderly frequent attender to the emergency department and 30-day mortality: A retrospective study over 10 years[J]. World Journal of Emergency Medicine, 2018, 9(1): 20-25.

Figures/Tables 6

Figure 1.

Table 1

Table 2

Table 3

Figure 2.

Table 4

Univariate and multivariate analysis of factors associated with 30-day mortality

Parameters	Univariate odds ratio		Multivariate adjusted odds ratio
Gender
Female	1
Male	1.36	(1.33, 1.4)	1.21	(1.17, 1.25)
Age
65 & above	-		-
Ethnicity
Chinese	1
Malay	0.98	(0.93, 1.04)	0.93	(0.88, 0.99)
Indian	0.65	(0.61, 0.70)	0.69	(0.64, 0.74)
Others	0.67	(0.61, 0.73)	0.64	(0.58, 0.71)
Distance to SGH-ED
0 to <5 km	1
5 to <10 km	0.91	(0.88, 0.95)	1.16	(1.12, 1.21)
10 to <15 km	0.91	(0.87, 0.94)	1.15	(1.11, 1.20)
15 km or more	0.96	(0.92, 1.01)	1.19	(1.13, 1.25)
Transport
Ambulance	4.27	(4.15, 4.4)	2.72	(2.63, 2.81)
Day of attendance
Monday	1.01	(0.96, 1.06)	1.03	(0.97, 1.09)
Tuesday	0.99	(0.94, 1.04)	1.00	(0.94, 1.06)
Wednesday	1.01	(0.96, 1.07)	1.01	(0.95, 1.07)
Thursday	0.99	(0.93, 1.04)	0.98	(0.92, 1.04)
Friday	1
Saturday	0.98	(0.92, 1.03)	0.97	(0.91, 1.03)
Sunday	1.14	(1.08, 1.20)	1.04	(0.98, 1.11)
Time of attendance
00:00-05:59 hours	1
06:00-11:59 hours	0.76	(0.72, 0.80)	1.10	(1.04, 1.18)
12:00-17:59 hours	0.81	(0.77, 0.86)	1.19	(1.12, 1.27)
18:00-23:59 hours	0.94	(0.89, 0.99)	1.17	(1.10, 1.24)
Triage priority
P1	1
P2	0.34	(0.33, 0.35)	0.45	(0.43, 0.46)
P3/P4	0.06	(0.06, 0.07)	0.14	(0.13, 0.15)
Attend previous year	1.34	(1.30, 1.38)	1.31	(1.26, 1.35)
FA	1.00	(0.97, 1.04)	-
3-6 visits	1.15	(1.12, 1.19)	0.77	(0.75, 0.80)
7 or more visits	0.54	(0.50, 0.59)	0.36	(0.33, 0.40)
Time to consultation	0.99	(0.98, 0.99)	1.00	(1.00, 1.00)
Time to disposition	1.00	(1.00, 1.00)	1.00	(1.00, 1.00)
ED diagnosis
Infectious diseases	1
Neoplasms	4.32	(4.06, 4.59)	5.32	(4.97, 5.69)
Immunity disorders	0.68	(0.64, 0.73)	0.75	(0.69, 0.80)
Blood diseases	0.74	(0.66, 0.83)	1.03	(0.91, 1.16)
Mental disorders	0.23	(0.16, 0.34)	0.33	(0.22, 0.48)
Nervous diseases	0.12	(0.10, 0.14)	0.25	(0.21, 0.29)
Circulatory diseases	0.55	(0.52, 0.59)	0.53	(0.49, 0.56)
Respiratory diseases	1.06	(1.00, 1.12)	0.96	(0.90, 1.02)
Digestive diseases	0.47	(0.44, 0.50)	0.73	(0.68, 0.79)
Genitourinary diseases	0.56	(0.51, 0.61)	0.90	(0.83, 0.98)
Skin diseases	0.25	(0.23, 0.28)	0.70	(0.62, 0.79)
Musculoskeletal diseases	0.12	(0.10, 0.13)	0.31	(0.27, 0.36)
Symptoms	0.36	(0.34, 0.39)	0.60	(0.56, 0.64)
Injury and poisoning	0.17	(0.16, 0.19)	0.32	(0.29, 0.35)
ED observation ward	0.09	(0.07, 0.12)	0.14	(0.11, 0.17)

Table 4

References 18

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Parameters	All attendance (n=1,381,180)	65 & above attendance (n=353,042)
Average per year
Total attendance	138,118	35,304
FA attendance	30,523	11,067
FA share of attendance	22.1	31.3
Average per year
Unique attendance	101,408	6,982
Unique FA attendance	7,121	816
FA share of unique attendance	7.0	11.7

Parameters	65 & above non-FA (n=242,371)	65 & above FA (n=110,671)	P values
Gender			< 0.001
Female	54.0	51.5
Male	46.0	48.5
Age			-
65 & above	100.0	100.0
85 & above	11.8	15.4
Ethnicity			< 0.001
Chinese	81.8	80.2
Malay	7.3	8.6
Indian	7.1	8.7
Others	3.7	2.5
Distance to SGH-ED
0 to <5 km	29.0	32.8
5 to <10 km	29.1	26.1
10 to <15 km	27.2	26.8
15 km or more	14.7	14.4
Transport			< 0.001
Ambulance	19.6	23.9
Day of attendance			< 0.001
Monday	16.6	15.8
Tuesday	14.7	14.6
Wednesday	14.1	14.1
Thursday	14.1	14.1
Friday	14.3	14.2
Saturday	14.0	14.1
Sunday	12.3	13.2
Time of attendance			< 0.001
00:00-05:59 hours	6.5	8.8
06:00-11:59 hours	29.9	29.0
12:00-17:59 hours	39.5	36.0
18:00-23:59 hours	24.1	26.2
Triage priority			< 0.001
P1	13.9	17.3
P2	53.3	59.6
P3/P4	32.8	23.1
Attended previous year	27.9	60.7	< 0.001
FA with 3-6 visits	-	81.2	-
FA with 7 or more visits	-	18.8	-

Parameters	65 & above non-FA (n=242,371)	65 & above FA (n=110,671)	P-values
Median time to consultation	36	32	<0.001
Median time to disposition	189	198	<0.001
Admission
Admitted	57.4	70.8	<0.001
Length of stay (median)	6	6	0.803
Admission diagnosis			<0.001
Infectious diseases	6.7	7.5
Neoplasms	2.5	3.3
Immunity disorders	5.3	7.9
Blood diseases	1.3	1.5
Mental disorders	0.3	0.4
Nervous diseases	4.3	1.9
Circulatory diseases	13.2	13.4
Respiratory diseases	8.6	12.0
Digestive diseases	8.3	9.0
Genitourinary diseases	3.7	5.6
Skin diseases	3.9	3.6
Musculoskeletal	4.9	3.7
General symptoms	23.5	24.5
Injury and poisoning	13.2	5.7
ED observation ward	4.0	2.5	<0.001
30-day mortality rate	5.4	5.4	0.764

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