Older People Often Get Final Care in EDs

Larry Hand

June 07, 2012

June 7, 2012 — Half of the people who died during a longitudinal study of older adults visited the emergency department (ED) at least once during the last month of life, 77% were subsequently hospitalized, and 68% of those hospitalized died in the hospital, according to a study published in the June issue of Health Affairs.

In contrast, people who entered hospice care at least a month before dying rarely visited EDs.

Alexander K. Smith, MD, MPH, a palliative medicine physician at San Francisco Veterans Administration Medical Center and an assistant professor of medicine in the Division of Geriatrics at University of California, San Francisco, and colleagues analyzed data from the Health and Retirement Study between 1992 and 2006 and compared those data with Medicare claims data. The Health and Retirement Study is an ongoing study by the National Institute on Aging on health, retirement, and aging.

The authors analyzed records of 8338 participants aged 65 years old and older who were enrolled in Medicare Parts A and B between 1992 and 2006, of whom 4585 participants died. For those patients, there were 4158 next-of-kin interviews during the study. The researchers then matched those records to participants who were alive when the other participants died to compare rates of ED visits; participants were matched based on age and sex.

The researchers found that 15% of the ED visits by the 8338 people were made by people who died within 6 months of a visit, and for people older than 84 years, 24% died within 6 months.

Of the 4158 who died and had next-of-kin interviews completed (mean age, 83 years; 53% women), 75% visited the ED at least once during the 6 months before death and 51% visited the ED at least once during the month before death compared with only 4% of people who were alive visiting the ED within a 1-month time frame. The top 3 reasons for visiting during the previous 6 months were congestive heart failure (8.0% of visits), pneumonia (6.6%), and acute stroke (4.9%). In addition, 77% of the patients who had died were dependent on others for at least 1 daily activity, 43% were cognitively impaired, and 46% experienced moderate to severe pain. Only 9% entered hospice care early, and 36% lived in nursing homes.

The researchers found that ED use in the last month of life varied by demographic and clinical factors and was more common in people "who were younger, Black or Hispanic, did not have cancer, had a history of a heart condition, had no cognitive impairments, and did not live in either in the Western United States or in an urban area."

"These high rates of emergency department use in the last months of life suggest opportunities for improvement in the outpatient setting," the researchers write. "As occurred in our sample, the last months of life for older adults are often characterized not by sudden death, but by chronic illness, pain, functional decline, and cognitive impairment."

Hospice Prevents ED Visits

Early enrollment in hospice was associated with 80% less use of EDs in this study compared with nonenrollment, and it "dramatically reduced rates of hospitalization and death in the hospital," the researchers write. The Medicare hospice benefit is available to individuals older than 65 years, and although recently it was criticized for spending increases, the criticism did not take into account potential avoidance of costly ED use, the authors write.

The researchers recommend that policies be adopted to encourage early hospice enrollment among older people, that EDs be supported in their efforts to incorporate palliative care in their services, and that primary care physicians provide patients and their families with end-of-life goals for care that fit patients' needs and preferences.

"Outpatient providers can help prepare families for the eventuality of death, including early referral to hospice and, where available, outpatient palliative care services," the researchers conclude. "Policies that require physicians to disclose a terminal prognosis and provide reimbursement for advance care planning should be encouraged."

The study was supported by the National Palliative Care Center; the National Center for Research Resources University of California, San Francisco, Clinical and Translational Science Institute; and the National Institute on Aging. The authors have disclosed no relevant financial relationships.

Health Aff. 2012;31:1277-1285. Abstract

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